Healthcare Provider Details

I. General information

NPI: 1992209571
Provider Name (Legal Business Name): STACY HODGES
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/20/2018
Last Update Date: 03/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1421 A-EAST PEACE STREET
CANTON MS
39046-3904
US

IV. Provider business mailing address

4109 HIGHWAY 98 W # 41
SUMMIT MS
39666-9132
US

V. Phone/Fax

Practice location:
  • Phone: 601-855-5760
  • Fax:
Mailing address:
  • Phone: 601-276-3900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberTA2344
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: