Provider Demographics
NPI:1285634725
Name:BODNER, ELLEN C (DPT)
Entity Type:Individual
Prefix:DR
First Name:ELLEN
Middle Name:C
Last Name:BODNER
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20809 UNION TPKE
Mailing Address - Street 2:
Mailing Address - City:OAKLAND GARDENS
Mailing Address - State:NY
Mailing Address - Zip Code:11364-3235
Mailing Address - Country:US
Mailing Address - Phone:718-479-6370
Mailing Address - Fax:718-464-0954
Practice Address - Street 1:20809 UNION TPKE
Practice Address - Street 2:
Practice Address - City:OAKLAND GARDENS
Practice Address - State:NY
Practice Address - Zip Code:11364-3235
Practice Address - Country:US
Practice Address - Phone:718-479-6370
Practice Address - Fax:718-464-0954
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-27
Last Update Date:2011-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYNYS4201225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
R28388Medicare UPIN
NY57415GMedicare PIN