Provider Demographics
NPI:1477194181
Name:BODENNER, ELIZABETH (LAC)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:BODENNER
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6023 SE CESAR E CHAVEZ BLVD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97202-7607
Mailing Address - Country:US
Mailing Address - Phone:360-628-3773
Mailing Address - Fax:
Practice Address - Street 1:3115 NE SANDY BLVD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232-2776
Practice Address - Country:US
Practice Address - Phone:503-701-8766
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-03
Last Update Date:2019-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist