Provider Demographics
NPI:1700101821
Name:HODGE, DERON ROSET (MFT)
Entity Type:Individual
Prefix:MRS
First Name:DERON
Middle Name:ROSET
Last Name:HODGE
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12970 3RD ST
Mailing Address - Street 2:
Mailing Address - City:CHINO
Mailing Address - State:CA
Mailing Address - Zip Code:91710-3464
Mailing Address - Country:US
Mailing Address - Phone:909-628-1201
Mailing Address - Fax:
Practice Address - Street 1:12970 3RD ST
Practice Address - Street 2:
Practice Address - City:CHINO
Practice Address - State:CA
Practice Address - Zip Code:91710-3464
Practice Address - Country:US
Practice Address - Phone:909-628-1201
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-31
Last Update Date:2013-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA47146106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist