Provider Demographics
NPI:1669857801
Name:BODAR, BROOKE
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:
Last Name:BODAR
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 1:1800 EDINBURGH ST
Mailing Address - Street 2:
Mailing Address - City:RAWLINS
Mailing Address - State:WY
Mailing Address - Zip Code:82301-4506
Mailing Address - Country:US
Mailing Address - Phone:307-324-8820
Mailing Address - Fax:307-333-0261
Practice Address - Street 1:4989 N 3RD ST
Practice Address - Street 2:
Practice Address - City:LARAMIE
Practice Address - State:WY
Practice Address - Zip Code:82072-9548
Practice Address - Country:US
Practice Address - Phone:307-745-8997
Practice Address - Fax:307-742-6146
Is Sole Proprietor?:No
Enumeration Date:2015-07-29
Last Update Date:2018-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
172V00000X
WY101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No172V00000XOther Service ProvidersCommunity Health Worker