Provider Demographics
NPI:1588915797
Name:HODGE, MOLLY MARIE (PT)
Entity type:Individual
Prefix:
First Name:MOLLY
Middle Name:MARIE
Last Name:HODGE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:MOLLY
Other - Middle Name:MARIE
Other - Last Name:LODER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:360 E MONTVUE DR STE 100
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-6318
Mailing Address - Country:US
Mailing Address - Phone:541-914-7632
Mailing Address - Fax:
Practice Address - Street 1:360 E MONTVUE DR STE 100
Practice Address - Street 2:STE 100
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-6318
Practice Address - Country:US
Practice Address - Phone:208-855-2900
Practice Address - Fax:208-855-2911
Is Sole Proprietor?:No
Enumeration Date:2012-09-27
Last Update Date:2017-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR6966225100000X
ID4376225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORP01153277OtherRR MEDICARE
WA500650978Medicaid
ORR167713Medicare PIN
WA500650978Medicaid