Provider Demographics
NPI:1447804893
Name:BODLE, SALLY JANE
Entity Type:Individual
Prefix:
First Name:SALLY
Middle Name:JANE
Last Name:BODLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:602 E LOCUST LN
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83686-8416
Mailing Address - Country:US
Mailing Address - Phone:208-546-1258
Mailing Address - Fax:
Practice Address - Street 1:602 E LOCUST LN
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83686-8416
Practice Address - Country:US
Practice Address - Phone:208-546-1258
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-24
Last Update Date:2019-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician