Provider Demographics
NPI:1194105122
Name:HODRICK, GWEN L (LPC)
Entity type:Individual
Prefix:
First Name:GWEN
Middle Name:L
Last Name:HODRICK
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:660 ACOMA BLVD N
Mailing Address - Street 2:
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86403-3662
Mailing Address - Country:US
Mailing Address - Phone:214-914-6775
Mailing Address - Fax:
Practice Address - Street 1:660 ACOMA BLVD N
Practice Address - Street 2:
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-3662
Practice Address - Country:US
Practice Address - Phone:214-702-6775
Practice Address - Fax:214-614-4725
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-04
Last Update Date:2022-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX12811101YA0400X
TX69392101YP2500X
AZ20753101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ164381Medicaid