Provider Demographics
NPI:1376971374
Name:BODEM, MICHAEL (BA)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:
Last Name:BODEM
Suffix:
Gender:M
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 DEERFIELD RD
Mailing Address - Street 2:
Mailing Address - City:WELLESLEY
Mailing Address - State:MA
Mailing Address - Zip Code:02481-1213
Mailing Address - Country:US
Mailing Address - Phone:781-223-3315
Mailing Address - Fax:
Practice Address - Street 1:360 MASSACHUSETTS AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:ACTON
Practice Address - State:MA
Practice Address - Zip Code:01720-3750
Practice Address - Country:US
Practice Address - Phone:978-460-8482
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-29
Last Update Date:2013-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical