Healthcare Provider Details

I. General information

NPI: 1083921720
Provider Name (Legal Business Name): JUSTIN HODGES
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/01/2010
Last Update Date: 02/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3556 EL CAMINO REAL
ATASCADERO CA
93422-2532
US

IV. Provider business mailing address

2180 JOHNSON AVE
SAN LUIS OBISPO CA
93401-4513
US

V. Phone/Fax

Practice location:
  • Phone: 805-461-6080
  • Fax:
Mailing address:
  • Phone: 805-540-8364
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: