Provider Demographics
NPI:1528387503
Name:BODNER, FAGIE (OT)
Entity Type:Individual
Prefix:
First Name:FAGIE
Middle Name:
Last Name:BODNER
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:858 E 24TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11210-2822
Mailing Address - Country:US
Mailing Address - Phone:718-258-3351
Mailing Address - Fax:
Practice Address - Street 1:858 E 24TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11210-2822
Practice Address - Country:US
Practice Address - Phone:718-258-3351
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-31
Last Update Date:2010-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010385-1171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor