Healthcare Provider Details

I. General information

NPI: 1720586076
Provider Name (Legal Business Name): ROSEMARY HODGES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/31/2018
Last Update Date: 06/21/2021
Certification Date: 06/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1919 E THOMAS RD
PHOENIX AZ
85016-7710
US

IV. Provider business mailing address

3200 E CAMELBACK RD STE 250
PHOENIX AZ
85018-2327
US

V. Phone/Fax

Practice location:
  • Phone: 602-933-0990
  • Fax: 602-933-4251
Mailing address:
  • Phone: 602-933-1813
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License NumberPSY005382
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: