Provider Demographics
NPI:1699475673
Name:HODGE, MALLORY (CPHT)
Entity type:Individual
Prefix:MRS
First Name:MALLORY
Middle Name:
Last Name:HODGE
Suffix:
Gender:F
Credentials:CPHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5225 WHITE WILLOW DR APT C230
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80528-5056
Mailing Address - Country:US
Mailing Address - Phone:970-413-3155
Mailing Address - Fax:
Practice Address - Street 1:3780 E 15TH ST STE 102
Practice Address - Street 2:
Practice Address - City:LOVELAND
Practice Address - State:CO
Practice Address - Zip Code:80538-8768
Practice Address - Country:US
Practice Address - Phone:970-461-1975
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-07
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO174H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator