Provider Demographics
NPI:1093168106
Name:BODENWEBER, ZACHARY
Entity Type:Individual
Prefix:
First Name:ZACHARY
Middle Name:
Last Name:BODENWEBER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:63 FLORENCE ST
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:NY
Mailing Address - Zip Code:12401-3017
Mailing Address - Country:US
Mailing Address - Phone:845-389-2016
Mailing Address - Fax:
Practice Address - Street 1:11 CRUM ELBOW RD
Practice Address - Street 2:
Practice Address - City:HYDE PARK
Practice Address - State:NY
Practice Address - Zip Code:12538-2852
Practice Address - Country:US
Practice Address - Phone:845-229-2005
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-13
Last Update Date:2016-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP02613104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker