Provider Demographics
NPI:1184969784
Name:BODNER, VICTORIA M (LMT)
Entity type:Individual
Prefix:MS
First Name:VICTORIA
Middle Name:M
Last Name:BODNER
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13314 DETROIT AVE
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44107-2850
Mailing Address - Country:US
Mailing Address - Phone:216-621-3043
Mailing Address - Fax:
Practice Address - Street 1:13314 DETROIT AVE
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:OH
Practice Address - Zip Code:44107-2850
Practice Address - Country:US
Practice Address - Phone:216-621-3043
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-07
Last Update Date:2016-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH33.007239225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist