Provider Demographics
NPI:1801011176
Name:BODE, ILA BREEANN 'BREE' (LMFT)
Entity Type:Individual
Prefix:MRS
First Name:ILA
Middle Name:BREEANN 'BREE'
Last Name:BODE
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5161 SOQUEL DR STE C
Mailing Address - Street 2:
Mailing Address - City:SOQUEL
Mailing Address - State:CA
Mailing Address - Zip Code:95073-2560
Mailing Address - Country:US
Mailing Address - Phone:831-515-7078
Mailing Address - Fax:833-312-0098
Practice Address - Street 1:5161 SOQUEL DR STE C
Practice Address - Street 2:
Practice Address - City:SOQUEL
Practice Address - State:CA
Practice Address - Zip Code:95073-2560
Practice Address - Country:US
Practice Address - Phone:831-515-7078
Practice Address - Fax:833-312-0098
Is Sole Proprietor?:No
Enumeration Date:2007-04-13
Last Update Date:2023-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA47139106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ91892ZOtherSANTA CRUZ COUNTY MEDICARE GROUP PTAN#