Provider Demographics
NPI:1578028106
Name:BODHI PSYCHOTHERAPY AND CONSULTING, LLC
Entity Type:Organization
Organization Name:BODHI PSYCHOTHERAPY AND CONSULTING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:MARILYN
Authorized Official - Middle Name:RENEE
Authorized Official - Last Name:GOLDMAN
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW-C, LISW-CP
Authorized Official - Phone:410-602-2545
Mailing Address - Street 1:PO BOX 10960
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21234-0960
Mailing Address - Country:US
Mailing Address - Phone:410-882-7967
Mailing Address - Fax:410-882-1079
Practice Address - Street 1:518 S MAIN ST OFC 6
Practice Address - Street 2:
Practice Address - City:SIMPSONVILLE
Practice Address - State:SC
Practice Address - Zip Code:29681-3220
Practice Address - Country:US
Practice Address - Phone:443-670-7977
Practice Address - Fax:410-882-1079
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-07
Last Update Date:2019-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty