Provider Demographics
NPI:1497223010
Name:BODNAR, MARISSA (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:
Last Name:BODNAR
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:520 NORTH ST
Mailing Address - Street 2:
Mailing Address - City:ELKTON
Mailing Address - State:MD
Mailing Address - Zip Code:21921-5610
Mailing Address - Country:US
Mailing Address - Phone:724-972-3467
Mailing Address - Fax:
Practice Address - Street 1:201 BOOTH ST
Practice Address - Street 2:
Practice Address - City:ELKTON
Practice Address - State:MD
Practice Address - Zip Code:21921-5618
Practice Address - Country:US
Practice Address - Phone:410-996-5450
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-13
Last Update Date:2023-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD08837235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD1497223010Medicaid