Basic Information
| Provider Information | |||||||||
| NPI: | 1851309694 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HODGE | ||||||||
| FirstName: | PATRICIA | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | NPP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 119 ROSEMONT AVE | ||||||||
| Address2: | |||||||||
| City: | FARMINGVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117382047 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6316982315 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1841 BRENTWOOD RD | ||||||||
| Address2: | |||||||||
| City: | BRENTWOOD | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117174625 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6318537300 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/04/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 339727 | NY | X | Nursing Service Providers | Registered Nurse | 363LP0808X | F400360 | NY | X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health | 364SP0809X | F400360 | NY | X | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Psych/Mental Health, Adult |
ID Information
| ID | Type | State | Issuer | Description | 97N0210 | 05 | NY | MEDICAID |