Provider Demographics
NPI:1689973984
Name:BODINE, EVIE E (LAPC)
Entity Type:Individual
Prefix:
First Name:EVIE
Middle Name:E
Last Name:BODINE
Suffix:
Gender:F
Credentials:LAPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:478 PENSDALE RD
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30030-1413
Mailing Address - Country:US
Mailing Address - Phone:678-310-5383
Mailing Address - Fax:
Practice Address - Street 1:1459 OXFORD RD NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30307-1046
Practice Address - Country:US
Practice Address - Phone:678-310-5383
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-25
Last Update Date:2016-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC 007612101Y00000X
GAMFT 001281106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist