Provider Demographics
NPI:1811467764
Name:HODGES, RAPHAELA
Entity type:Individual
Prefix:
First Name:RAPHAELA
Middle Name:
Last Name:HODGES
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 1:5311 HERMITAGE AVE APT 8
Mailing Address - Street 2:
Mailing Address - City:VALLEY VILLAGE
Mailing Address - State:CA
Mailing Address - Zip Code:91607-4260
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5311 HERMITAGE AVE APT 8
Practice Address - Street 2:
Practice Address - City:VALLEY VILLAGE
Practice Address - State:CA
Practice Address - Zip Code:91607-4260
Practice Address - Country:US
Practice Address - Phone:323-595-0928
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-03
Last Update Date:2018-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA107694106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist