Provider Demographics
NPI:1871833392
Name:BODENBERG, KATHERINE (DC)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:
Last Name:BODENBERG
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 1:715 HOLLOW RD
Mailing Address - Street 2:
Mailing Address - City:ELLICOTT CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21043-4717
Mailing Address - Country:US
Mailing Address - Phone:717-870-7016
Mailing Address - Fax:
Practice Address - Street 1:715 HOLLOW RD
Practice Address - Street 2:
Practice Address - City:ELLICOTT CITY
Practice Address - State:MD
Practice Address - Zip Code:21043-4717
Practice Address - Country:US
Practice Address - Phone:717-870-7016
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-20
Last Update Date:2020-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDS03724111NS0005X, 111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No111NS0005XChiropractic ProvidersChiropractorSports PhysicianGroup - Multi-Specialty