Provider Demographics
NPI:1063859122
Name:BODEN, MICHELLE RAE (LMT)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:RAE
Last Name:BODEN
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1050 CLEVELAND AVE
Mailing Address - Street 2:
Mailing Address - City:AMHERST
Mailing Address - State:OH
Mailing Address - Zip Code:44001-1746
Mailing Address - Country:US
Mailing Address - Phone:440-225-1168
Mailing Address - Fax:
Practice Address - Street 1:5361 OBERLIN AVE
Practice Address - Street 2:
Practice Address - City:LORAIN
Practice Address - State:OH
Practice Address - Zip Code:44053-3437
Practice Address - Country:US
Practice Address - Phone:440-282-7132
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-30
Last Update Date:2013-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH012358225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist