Healthcare Provider Details

I. General information

NPI: 1629067947
Provider Name (Legal Business Name): MARY HODGKINS LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/19/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

655 7TH ST 78 MDG/SGOHF
ROBINS AFB GA
31098-2227
US

IV. Provider business mailing address

PO BOX 912
PERRY GA
31069-0912
US

V. Phone/Fax

Practice location:
  • Phone: 478-327-8398
  • Fax: 478-327-8426
Mailing address:
  • Phone: 478-327-8398
  • Fax: 478-326-8426

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCSW001461
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: