Provider Demographics
NPI:1184205551
Name:BODROG, LAURA (LCSW)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:BODROG
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 FOXCROFT WAY
Mailing Address - Street 2:
Mailing Address - City:MOUNT LAUREL
Mailing Address - State:NJ
Mailing Address - Zip Code:08054-5733
Mailing Address - Country:US
Mailing Address - Phone:856-912-7845
Mailing Address - Fax:
Practice Address - Street 1:11 FOXCROFT WAY
Practice Address - Street 2:
Practice Address - City:MOUNT LAUREL
Practice Address - State:NJ
Practice Address - Zip Code:08054-5733
Practice Address - Country:US
Practice Address - Phone:856-912-7845
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-17
Last Update Date:2021-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ1041S0200X
NJ44SC053987001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool