Healthcare Provider Details

I. General information

NPI: 1306906581
Provider Name (Legal Business Name): C. SONNY HODGDON JR. MSW, LCSW, LAT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/11/2006
Last Update Date: 12/08/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 FOOTHILL BLVD
ROCK SPRINGS WY
82901
US

IV. Provider business mailing address

2300 FOOTHILL BLVD
ROCK SPRINGS WY
82901
US

V. Phone/Fax

Practice location:
  • Phone: 307-352-6677
  • Fax: 307-352-6614
Mailing address:
  • Phone: 307-352-6677
  • Fax: 307-352-6614

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLAT-160
License Number StateWY
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW-543
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: