Provider Demographics
NPI:1790023182
Name:POTTER-BODENLOS, DANIELLE PATRICE (DC)
Entity Type:Individual
Prefix:MISS
First Name:DANIELLE
Middle Name:PATRICE
Last Name:POTTER-BODENLOS
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7198 FAY DR
Mailing Address - Street 2:
Mailing Address - City:VAN BUREN TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48111-1118
Mailing Address - Country:US
Mailing Address - Phone:734-455-6767
Mailing Address - Fax:734-455-2359
Practice Address - Street 1:6231 N CANTON CENTER RD
Practice Address - Street 2:SUITE 109
Practice Address - City:CANTON
Practice Address - State:MI
Practice Address - Zip Code:48187-2694
Practice Address - Country:US
Practice Address - Phone:734-455-6767
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-21
Last Update Date:2021-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301010064111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor