Provider Demographics
NPI:1306286240
Name:HODGE, KYEISHA (MSED)
Entity type:Individual
Prefix:
First Name:KYEISHA
Middle Name:
Last Name:HODGE
Suffix:
Gender:F
Credentials:MSED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29 RICHARD AVE
Mailing Address - Street 2:
Mailing Address - City:WEST CALDWELL
Mailing Address - State:NJ
Mailing Address - Zip Code:07006-7245
Mailing Address - Country:US
Mailing Address - Phone:646-420-7750
Mailing Address - Fax:
Practice Address - Street 1:29 RICHARD AVE
Practice Address - Street 2:
Practice Address - City:WEST CALDWELL
Practice Address - State:NJ
Practice Address - Zip Code:07006-7245
Practice Address - Country:US
Practice Address - Phone:646-420-7750
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-25
Last Update Date:2024-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
WALH60680488101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)