Provider Demographics
NPI:1750815452
Name:BODENBENDER, BROCK OWEN (LPCC)
Entity Type:Individual
Prefix:
First Name:BROCK
Middle Name:OWEN
Last Name:BODENBENDER
Suffix:
Gender:M
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17951 JEFFERSON PARK RD STE 100
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBURG HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44130-8439
Mailing Address - Country:US
Mailing Address - Phone:440-879-8517
Mailing Address - Fax:
Practice Address - Street 1:17951 JEFFERSON PARK RD STE 100
Practice Address - Street 2:
Practice Address - City:MIDDLEBURG HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44130-8439
Practice Address - Country:US
Practice Address - Phone:440-879-8517
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-19
Last Update Date:2022-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE.2001912101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0267340Medicaid