Provider Demographics
NPI:1275859811
Name:BODINE, DEENA S (LCSW)
Entity Type:Individual
Prefix:MS
First Name:DEENA
Middle Name:S
Last Name:BODINE
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 1:415 MULBERRY STREET
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47713-1230
Mailing Address - Country:US
Mailing Address - Phone:812-423-7791
Mailing Address - Fax:812-422-7558
Practice Address - Street 1:60 S STOCKWELL RD
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47714-0247
Practice Address - Country:US
Practice Address - Phone:812-476-5437
Practice Address - Fax:812-422-7558
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-07
Last Update Date:2014-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34005487A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100240880Medicaid
IN000000752280OtherANTHEM
IN12138474OtherCAQH
IN100240880Medicaid