Healthcare Provider Details

I. General information

NPI: 1306096714
Provider Name (Legal Business Name): ROGER GRAYSON HODGE PSY.D. LCP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/22/2008
Last Update Date: 12/06/2023
Certification Date: 12/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4025 CAMINO DEL RIO S STE 250
SAN DIEGO CA
92108-4100
US

IV. Provider business mailing address

PO BOX 2207
EL CAJON CA
92021
US

V. Phone/Fax

Practice location:
  • Phone: 619-858-3105
  • Fax: 619-280-5420
Mailing address:
  • Phone: 760-500-1781
  • Fax: 619-449-8923

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number26148
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMFC44634
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: