Healthcare Provider Details

I. General information

NPI: 1124599220
Provider Name (Legal Business Name): STACEY HODGDON BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: STACEY LEIGH SMITH

II. Dates (important events)

Enumeration Date: 12/16/2018
Last Update Date: 07/02/2026
Certification Date: 07/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

255 E RINCON ST STE 219
CORONA CA
92879-1387
US

IV. Provider business mailing address

255 E RINCON ST STE 219
CORONA CA
92879-1387
US

V. Phone/Fax

Practice location:
  • Phone: 951-817-5328
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-16-23695
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: