Provider Demographics
NPI:1871597260
Name:HODGE, MARY CANDACE (PT)
Entity type:Individual
Prefix:MISS
First Name:MARY
Middle Name:CANDACE
Last Name:HODGE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2308 RIDGE RD
Mailing Address - Street 2:STE C
Mailing Address - City:ROCKWALL
Mailing Address - State:TX
Mailing Address - Zip Code:75087-5154
Mailing Address - Country:US
Mailing Address - Phone:972-772-3767
Mailing Address - Fax:972-722-1868
Practice Address - Street 1:2308 RIDGE RD
Practice Address - Street 2:STE C
Practice Address - City:ROCKWALL
Practice Address - State:TX
Practice Address - Zip Code:75087-5154
Practice Address - Country:US
Practice Address - Phone:972-772-3767
Practice Address - Fax:972-722-1868
Is Sole Proprietor?:No
Enumeration Date:2005-06-13
Last Update Date:2007-07-24
Deactivation Date:2006-03-16
Deactivation Code:
Reactivation Date:2006-03-22
Provider Licenses
StateLicense IDTaxonomies
TX1065225225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX659527OtherBLUECROSS
TXS80487Medicare UPIN
TX659527OtherBLUECROSS