Basic Information
| Provider Information | |||||||||
| NPI: | 1851661623 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HODGE | ||||||||
| FirstName: | JULIETTE | ||||||||
| MiddleName: | LACE | ||||||||
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| Credential: | MA,BA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 141 E MAIN ST | ||||||||
| Address2: | 4TH FLOOR ADMINISTRATION | ||||||||
| City: | WATERBURY | ||||||||
| State: | CT | ||||||||
| PostalCode: | 067022310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2035749000 | ||||||||
| FaxNumber: | 2035749006 | ||||||||
| Practice Location | |||||||||
| Address1: | 160 MIDLAN ROAD | ||||||||
| Address2: | WELLMORE, INC-PALADIN HOUSE | ||||||||
| City: | WATERBURY | ||||||||
| State: | CT | ||||||||
| PostalCode: | 067053415 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2035971935 | ||||||||
| FaxNumber: | 2035978811 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/10/2012 | ||||||||
| LastUpdateDate: | 04/08/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | Y | Behavioral Health & Social Service Providers | Counselor |
No ID Information.