Basic Information
| Provider Information | |||||||||
| NPI: | 1710106521 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HODGENS | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | BART | ||||||||
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| Credential: | PH.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 700 8TH AVE W STE 101 | ||||||||
| Address2: | |||||||||
| City: | PALMETTO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342214737 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9417764000 | ||||||||
| FaxNumber: | 9418454963 | ||||||||
| Practice Location | |||||||||
| Address1: | 5325 26TH ST W | ||||||||
| Address2: | |||||||||
| City: | BRADENTON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342073012 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9417527173 | ||||||||
| FaxNumber: | 9415676277 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/24/2007 | ||||||||
| LastUpdateDate: | 11/09/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC2200X | 475 | AL | N | Behavioral Health & Social Service Providers | Psychologist | Clinical Child & Adolescent | 103TC0700X | PY8338 | FL | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 003995100 | 05 | FL | MEDICAID | 051075068 | 01 | AL | BLUECROSS AND BLUESHIELD | OTHER | 000075068 | 05 | LA | MEDICAID |