Provider Demographics
NPI:1285124099
Name:HODGE, MARIAH SOMMER (BCBA)
Entity type:Individual
Prefix:MRS
First Name:MARIAH
Middle Name:SOMMER
Last Name:HODGE
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:MRS
Other - First Name:MARIAH
Other - Middle Name:SOMMER
Other - Last Name:HODGE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:BCBA
Mailing Address - Street 1:19 HILLTOP DR
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MS
Mailing Address - Zip Code:39443-0979
Mailing Address - Country:US
Mailing Address - Phone:601-470-7128
Mailing Address - Fax:601-470-7128
Practice Address - Street 1:32 MILLBRANCH RD STE 40
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402-1673
Practice Address - Country:US
Practice Address - Phone:601-255-5264
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-16
Last Update Date:2022-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSRBT-18-55442106S00000X
MS1-22-58133103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSRBT-18-55442OtherRBT
MS220016OtherLBA
1-22-58133OtherBCBA