MEDICARE: MR. FREDRICK DOUGLAS HODGES LCSW, CASAC-G

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	078144	NY

General Provider Information

NPI Number	:	1174958250
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. FREDRICK DOUGLAS HODGES LCSW, CASAC-G

Provider Business Mailing Address
First Line	:	3398 WAYNE AVE
Second Line	:	#C42
City	:	BRONX
State	:	NY
Zip	:	10467-2417
Country	:	US
Telephone Number	:	347-964-6704
Fax Number	:	347-326-6409

Provider Business Practice Location Address
First Line	:	3398 WAYNE AVE
Second Line	:	#C42
City	:	BRONX
State	:	NY
Zip	:	10467-2417
Country	:	US
Telephone Number	:	347-964-6704
Fax Number	:	347-326-6409

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/09/2013
Last Update Date	:	09/09/2013

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