Provider Demographics
NPI:1508909532
Name:BODENHAFER, JAMIE LORRAINE (LMSW)
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:LORRAINE
Last Name:BODENHAFER
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17657 AVILLA BLVD
Mailing Address - Street 2:
Mailing Address - City:LATHRUP VILLAGE
Mailing Address - State:MI
Mailing Address - Zip Code:48076-2732
Mailing Address - Country:US
Mailing Address - Phone:248-259-3527
Mailing Address - Fax:248-557-2008
Practice Address - Street 1:17657 AVILLA BLVD
Practice Address - Street 2:
Practice Address - City:LATHRUP VILLAGE
Practice Address - State:MI
Practice Address - Zip Code:48076-2732
Practice Address - Country:US
Practice Address - Phone:248-259-3527
Practice Address - Fax:248-557-2008
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-15
Last Update Date:2014-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010870811041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical