Provider Demographics
NPI:1629479860
Name:BODENMUELLER, MONIA
Entity Type:Individual
Prefix:
First Name:MONIA
Middle Name:
Last Name:BODENMUELLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31 ORKNEY RD UNIT 41
Mailing Address - Street 2:
Mailing Address - City:BRIGHTON
Mailing Address - State:MA
Mailing Address - Zip Code:02134
Mailing Address - Country:US
Mailing Address - Phone:617-650-2454
Mailing Address - Fax:
Practice Address - Street 1:92 UNION SQ
Practice Address - Street 2:
Practice Address - City:SOMERVILLE
Practice Address - State:MA
Practice Address - Zip Code:02143-3028
Practice Address - Country:US
Practice Address - Phone:617-764-2091
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-08
Last Update Date:2014-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health