Provider Demographics
NPI:1942171012
Name:HODGIN, EMMALINE KATHLEEN
Entity type:Individual
Prefix:
First Name:EMMALINE
Middle Name:KATHLEEN
Last Name:HODGIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:EMMALINE
Other - Middle Name:KATHLEEN
Other - Last Name:KIDDER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:617 S 13TH ST APT 202
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-6807
Mailing Address - Country:US
Mailing Address - Phone:208-340-9996
Mailing Address - Fax:
Practice Address - Street 1:921 S ORCHARD ST STE 100
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83705-1916
Practice Address - Country:US
Practice Address - Phone:208-344-9797
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-09-13
Last Update Date:2025-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID20-250320Medicaid