Provider Demographics
NPI:1356770879
Name:HODGE, KELLY (LPC-MHSP)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:HODGE
Suffix:
Gender:F
Credentials:LPC-MHSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:441 E BROAD ST STE D
Mailing Address - Street 2:
Mailing Address - City:COOKEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38501-3390
Mailing Address - Country:US
Mailing Address - Phone:931-265-5706
Mailing Address - Fax:
Practice Address - Street 1:441 E BROAD ST STE D
Practice Address - Street 2:
Practice Address - City:COOKEVILLE
Practice Address - State:TN
Practice Address - Zip Code:38501-3390
Practice Address - Country:US
Practice Address - Phone:931-265-5706
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-05
Last Update Date:2019-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3916101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ052793Medicaid