Provider Demographics
NPI:1225693732
Name:BODENDORF, AMANDA ASHLEY (MSW)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:ASHLEY
Last Name:BODENDORF
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 JAYNE AVE
Mailing Address - Street 2:
Mailing Address - City:PATCHOGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11772-2835
Mailing Address - Country:US
Mailing Address - Phone:631-901-4244
Mailing Address - Fax:
Practice Address - Street 1:939 JOHNSON AVE
Practice Address - Street 2:
Practice Address - City:RONKONKOMA
Practice Address - State:NY
Practice Address - Zip Code:11779-6066
Practice Address - Country:US
Practice Address - Phone:631-471-7242
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-09
Last Update Date:2019-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY106441-1104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker