Provider Demographics
NPI:1245382373
Name:BODINE, VENA P (MA LPC)
Entity Type:Individual
Prefix:MS
First Name:VENA
Middle Name:P
Last Name:BODINE
Suffix:
Gender:F
Credentials:MA LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W3020 WEAVER RD
Mailing Address - Street 2:
Mailing Address - City:ELKHORN
Mailing Address - State:WI
Mailing Address - Zip Code:53121
Mailing Address - Country:US
Mailing Address - Phone:262-723-8082
Mailing Address - Fax:
Practice Address - Street 1:740 N WISCONSIN AVE
Practice Address - Street 2:
Practice Address - City:EKLHORN
Practice Address - State:WI
Practice Address - Zip Code:53121
Practice Address - Country:US
Practice Address - Phone:262-723-7056
Practice Address - Fax:262-723-4692
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3431125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43592000Medicaid