Provider Demographics
NPI:1346576303
Name:BODENHAMER, MICHELLE (DPT)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:BODENHAMER
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:PO BOX 129
Mailing Address - Street 2:
Mailing Address - City:DRIGGS
Mailing Address - State:ID
Mailing Address - Zip Code:83422-0129
Mailing Address - Country:US
Mailing Address - Phone:253-273-3200
Mailing Address - Fax:
Practice Address - Street 1:50 SKI HILL RD
Practice Address - Street 2:
Practice Address - City:DRIGGS
Practice Address - State:ID
Practice Address - Zip Code:83422-0129
Practice Address - Country:US
Practice Address - Phone:208-354-3128
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-27
Last Update Date:2009-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT2609225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1378483OtherGROUP NPI