Healthcare Provider Details

I. General information

NPI: 1164349486
Provider Name (Legal Business Name): GRACIE RAE HODGES
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/30/2026
Last Update Date: 06/30/2026
Certification Date: 06/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2323 DARBY RD APT 312
HAVERTOWN PA
19083-2240
US

IV. Provider business mailing address

2323 DARBY RD APT 312
HAVERTOWN PA
19083-2240
US

V. Phone/Fax

Practice location:
  • Phone: 310-912-1825
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberPC020592
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: