Basic Information
| Provider Information | |||||||||
| NPI: | 1497018329 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HODGES | ||||||||
| FirstName: | LAURA | ||||||||
| MiddleName: | ELAINE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 345 BLACKSTONE BLVD | ||||||||
| Address2: | |||||||||
| City: | PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029064800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4014556373 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 345 BLACKSTONE BLVD | ||||||||
| Address2: | PSYCHIATRY RESIDENCY TRAINING PROGRAM, BUTLER HOSPITAL | ||||||||
| City: | PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029064800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4014556375 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2012 | ||||||||
| LastUpdateDate: | 07/15/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/15/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 2020-01410 | NC | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084P0800X | CLP02609 | RI | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | NNB583A | 01 | NC | PTAN | OTHER | NNB5830299 | 01 | NC | PTAN (PSYCHIATRY) | OTHER | 1497018329 | 05 | NC | MEDICAID |