Provider Demographics
NPI:1306096714
Name:HODGE, ROGER GRAYSON (PSYD LCP)
Entity type:Individual
Prefix:
First Name:ROGER
Middle Name:GRAYSON
Last Name:HODGE
Suffix:
Gender:M
Credentials:PSYD LCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2207
Mailing Address - Street 2:
Mailing Address - City:EL CAJON
Mailing Address - State:CA
Mailing Address - Zip Code:92021
Mailing Address - Country:US
Mailing Address - Phone:760-500-1781
Mailing Address - Fax:619-449-8923
Practice Address - Street 1:4025 CAMINO DEL RIO S STE 250
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-4100
Practice Address - Country:US
Practice Address - Phone:619-858-3105
Practice Address - Fax:619-280-5420
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-22
Last Update Date:2023-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC44634106H00000X
CA26148103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist