Provider Demographics
NPI:1891761391
Name:BODNAR, LINDA MARIE (LCSW)
Entity Type:Individual
Prefix:
First Name:LINDA
Middle Name:MARIE
Last Name:BODNAR
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1618 E LASALLE AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-2608
Mailing Address - Country:US
Mailing Address - Phone:574-229-3626
Mailing Address - Fax:
Practice Address - Street 1:17903 S.R. 23
Practice Address - Street 2:SUITE # 3
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46635
Practice Address - Country:US
Practice Address - Phone:574-277-2525
Practice Address - Fax:574-243-7735
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-24
Last Update Date:2010-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34001331A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
S20403Medicare UPIN
IN2375806Medicare ID - Type Unspecified