Provider Demographics
NPI:1386310746
Name:HODSON, WILFRED DALE (CPRM DEVELOPMENT PLA)
Entity type:Individual
Prefix:MR
First Name:WILFRED
Middle Name:DALE
Last Name:HODSON
Suffix:
Gender:M
Credentials:CPRM DEVELOPMENT PLA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1121 E MCNICHOLS RD
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48203-2857
Mailing Address - Country:US
Mailing Address - Phone:313-365-3100
Mailing Address - Fax:
Practice Address - Street 1:1468 WOODLAND DR
Practice Address - Street 2:
Practice Address - City:INKSTER
Practice Address - State:MI
Practice Address - Zip Code:48141-1744
Practice Address - Country:US
Practice Address - Phone:313-784-6463
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-17
Last Update Date:2021-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist