MEDICARE: GWEN L HODRICK LPC

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	12811	TX
2	101YP2500X	Professional Counselor	69392	TX
3	101YA0400X	Addiction (Substance Use Disorder) Counselor	20753	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1194105122
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GWEN L HODRICK LPC

Provider Business Mailing Address
First Line	:	660 ACOMA BLVD N
Second Line	:
City	:	LAKE HAVASU CITY
State	:	AZ
Zip	:	86403-3662
Country	:	US
Telephone Number	:	214-914-6775
Fax Number	:

Provider Business Practice Location Address
First Line	:	660 ACOMA BLVD N
Second Line	:
City	:	LAKE HAVASU CITY
State	:	AZ
Zip	:	86403-3662
Country	:	US
Telephone Number	:	214-702-6775
Fax Number	:	214-614-4725

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

Provider Enumeration Date	:	06/04/2015
Last Update Date	:	09/28/2022

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