Provider Demographics
NPI:1811456817
Name:HODGE, PAMELA ALEASIA
Entity type:Individual
Prefix:
First Name:PAMELA
Middle Name:ALEASIA
Last Name:HODGE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3240 FOREST RUN DR
Mailing Address - Street 2:
Mailing Address - City:DISTRICT HEIGHTS
Mailing Address - State:MD
Mailing Address - Zip Code:20747-3262
Mailing Address - Country:US
Mailing Address - Phone:301-830-3684
Mailing Address - Fax:
Practice Address - Street 1:3600 LEONARDTOWN RD STE 203
Practice Address - Street 2:
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20601-3647
Practice Address - Country:US
Practice Address - Phone:240-607-2679
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-19
Last Update Date:2019-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCLG102414104100000X
MD24643104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker