Healthcare Provider Details

I. General information

NPI: 1295359115
Provider Name (Legal Business Name): HODGES-METAMORPHOSIS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/05/2020
Last Update Date: 02/03/2022
Certification Date: 02/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

241 HUDSON ST STE 33
HACKENSACK NJ
07601-6708
US

IV. Provider business mailing address

100 SELVAGE AVE
TEANECK NJ
07666-4819
US

V. Phone/Fax

Practice location:
  • Phone: 201-255-7348
  • Fax: 201-255-7352
Mailing address:
  • Phone: 973-444-5341
  • Fax: 201-255-7352

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code177F00000X
TaxonomyLodging Provider
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier721247
Identifier TypeMEDICAID
Identifier StateNJ
Identifier Issuer

VIII. Authorized Official

Name: MARETTTA HODGES HODGES
Title or Position: EXECUTIVE DIRECTOR
Credential: ED.M, MSW
Phone: 973-444-5341