1114155025 NPI number — MS. EILEEN GRACE HODIAK LCSW, LEAP

Table of content: MS. EILEEN GRACE HODIAK LCSW, LEAP (NPI 1114155025)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114155025 NPI number — MS. EILEEN GRACE HODIAK LCSW, LEAP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HODIAK
Provider First Name:
EILEEN
Provider Middle Name:
GRACE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
LCSW, LEAP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1114155025
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/30/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
104 DRAGON FLY CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTHERN PINES
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28387-6476
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
910-692-4629
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
WOMACK ARMY MEDICAL CTR
Provider Second Line Business Practice Location Address:
2817 REILLY ROAD
Provider Business Practice Location Address City Name:
FORT BRAGG
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28310-0001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-907-6246
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/30/2009

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  C002780 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2024 www.npivalidator.com