Provider Demographics
NPI:1235181371
Name:BODGE, SANDRA CECELIA (CASE MANAGER)
Entity Type:Individual
Prefix:MS
First Name:SANDRA
Middle Name:CECELIA
Last Name:BODGE
Suffix:
Gender:F
Credentials:CASE MANAGER
Other - Prefix:
Other - First Name:SANDRA
Other - Middle Name:
Other - Last Name:BODGE KAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMHC
Mailing Address - Street 1:POB 2916
Mailing Address - Street 2:
Mailing Address - City:RANCHOS DE TAOS
Mailing Address - State:NM
Mailing Address - Zip Code:87557
Mailing Address - Country:US
Mailing Address - Phone:505-770-2404
Mailing Address - Fax:
Practice Address - Street 1:67 SUGAR LN
Practice Address - Street 2:
Practice Address - City:EL PRADO
Practice Address - State:NM
Practice Address - Zip Code:87529
Practice Address - Country:US
Practice Address - Phone:575-770-2404
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-17
Last Update Date:2024-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMT-0096331101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health