Provider Demographics
NPI:1851830442
Name:BODDIE, COURTNEY R (PHD)
Entity Type:Individual
Prefix:DR
First Name:COURTNEY
Middle Name:R
Last Name:BODDIE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:SOUTHERN ILLINOIS UNIVERSITY - EDWARDSVILLE
Mailing Address - Street 2:1 HAIRPIN DRIVE, SUITE 0222
Mailing Address - City:EDWARDSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62026-1852
Mailing Address - Country:US
Mailing Address - Phone:618-401-7407
Mailing Address - Fax:
Practice Address - Street 1:SOUTHERN ILLINOIS UNIVERSITY - EDWARDSVILLE
Practice Address - Street 2:1 HAIRPIN DRIVE, SUITE 0222
Practice Address - City:EDWARDSVILLE
Practice Address - State:IL
Practice Address - Zip Code:62026-1852
Practice Address - Country:US
Practice Address - Phone:618-401-7407
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-16
Last Update Date:2020-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180012537101YM0800X
MO2016010174101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health