Provider Demographics
NPI:1912950999
Name:HODDER, KENNETH W (LISW)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:W
Last Name:HODDER
Suffix:
Gender:M
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 ALAMEDA BLVD NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87114-1937
Mailing Address - Country:US
Mailing Address - Phone:505-897-7883
Mailing Address - Fax:505-792-8578
Practice Address - Street 1:1100 ALAMEDA BLVD NW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87114-1937
Practice Address - Country:US
Practice Address - Phone:505-897-7883
Practice Address - Fax:505-792-8578
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-18
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMI-2148104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM105879OtherMHN
NM860663612 0001OtherCIGNA HEALTHCARE
NM86066361287114A001OtherTRIWEST HEALTHCARE ALLIAN
NMNM10005Medicaid
NM00NM00R32LOtherBLUE CROSS BLUE SHIELD