Basic Information
Provider Information | |||||||||
NPI: | 1912336496 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HODGE | ||||||||
FirstName: | JANET | ||||||||
MiddleName: | A. | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | LMFT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 10100 ELIDA RD | ||||||||
Address2: |   | ||||||||
City: | DELPHOS | ||||||||
State: | OH | ||||||||
PostalCode: | 458339058 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4196958010 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1169 EASTERN PKWY STE 3364 | ||||||||
Address2: |   | ||||||||
City: | LOUISVILLE | ||||||||
State: | KY | ||||||||
PostalCode: | 402171415 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5028138280 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/05/2013 | ||||||||
LastUpdateDate: | 11/09/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 11/09/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | 105427 | KY | Y |   | Behavioral Health & Social Service Providers | Marriage & Family Therapist |   |
ID Information
ID | Type | State | Issuer | Description | 300047068 | 05 | IN |   | MEDICAID | 7100277970 | 05 | KY |   | MEDICAID |