Healthcare Provider Details

I. General information

NPI: 1639443138
Provider Name (Legal Business Name): DAMASO ALLEN HODGES LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/01/2012
Last Update Date: 11/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1639 W FOSTER AVE APT 2
CHICAGO IL
60640-2086
US

IV. Provider business mailing address

1996 APACHE TRL
ROUND LAKE BEACH IL
60073-1365
US

V. Phone/Fax

Practice location:
  • Phone: 330-280-3032
  • Fax:
Mailing address:
  • Phone: 330-280-3032
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number150101823
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149021755
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: