Provider Demographics
NPI:1134182058
Name:HODGES, SEAN (PHD)
Entity type:Individual
Prefix:DR
First Name:SEAN
Middle Name:
Last Name:HODGES
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 2ND ST
Mailing Address - Street 2:#2
Mailing Address - City:IMPERIAL BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:91932-2501
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:549 ORANGE AVE # 213
Practice Address - Street 2:
Practice Address - City:CORONADO
Practice Address - State:CA
Practice Address - Zip Code:92118-1826
Practice Address - Country:US
Practice Address - Phone:619-996-3195
Practice Address - Fax:619-996-3196
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-11
Last Update Date:2020-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY20658103TC0700X
CA20658103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWCP20658CMedicare PIN
CACP20658Medicare ID - Type Unspecified