Healthcare Provider Details

I. General information

NPI: 1881664506
Provider Name (Legal Business Name): DONALD GENE HODGSON D.MIN. (PSYCH)
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/25/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

202 WOODFORD ST
PORTLAND ME
04103-5602
US

IV. Provider business mailing address

202 WOODFORD ST
PORTLAND ME
04103-5602
US

V. Phone/Fax

Practice location:
  • Phone: 207-774-8243
  • Fax: 207-773-3317
Mailing address:
  • Phone: 207-774-8243
  • Fax: 207-773-3317

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCC857
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: