Provider Demographics
NPI:1104129782
Name:JAMIE L BODENHAFER LLC
Entity type:Organization
Organization Name:JAMIE L BODENHAFER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINCAL SOCIAL WORKER/ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JAMIE
Authorized Official - Middle Name:LORRAINE
Authorized Official - Last Name:BODENHAFER
Authorized Official - Suffix:
Authorized Official - Credentials:LMSW
Authorized Official - Phone:248-259-3527
Mailing Address - Street 1:17657 AVILLA BLVD
Mailing Address - Street 2:
Mailing Address - City:LATHRUP VILLAGE
Mailing Address - State:MI
Mailing Address - Zip Code:48076-2732
Mailing Address - Country:US
Mailing Address - Phone:248-259-3527
Mailing Address - Fax:
Practice Address - Street 1:17657 AVILLA BLVD
Practice Address - Street 2:
Practice Address - City:LATHRUP VILLAGE
Practice Address - State:MI
Practice Address - Zip Code:48076-2732
Practice Address - Country:US
Practice Address - Phone:248-259-3527
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-21
Last Update Date:2010-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010870811041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty