Provider Demographics
NPI:1730397514
Name:HODGDON, ROBERTA KATHRYN (LAC)
Entity type:Individual
Prefix:MS
First Name:ROBERTA
Middle Name:KATHRYN
Last Name:HODGDON
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18410 PRIORY AVE
Mailing Address - Street 2:
Mailing Address - City:MINNETONKA
Mailing Address - State:MN
Mailing Address - Zip Code:55345-2459
Mailing Address - Country:US
Mailing Address - Phone:952-470-5832
Mailing Address - Fax:
Practice Address - Street 1:18410 PRIORY AVE
Practice Address - Street 2:
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55345-2459
Practice Address - Country:US
Practice Address - Phone:952-470-5832
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1034171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist