Provider Demographics
NPI:1205455664
Name:BODENHAMER, BROOK ELIZABETH (LCSW, LCDC)
Entity type:Individual
Prefix:MRS
First Name:BROOK
Middle Name:ELIZABETH
Last Name:BODENHAMER
Suffix:
Gender:F
Credentials:LCSW, LCDC
Other - Prefix:MISS
Other - First Name:BROOK
Other - Middle Name:ELIZABETH
Other - Last Name:SCHMIDT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:204 W TRAILMOOR DR
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:TX
Mailing Address - Zip Code:78624-3423
Mailing Address - Country:US
Mailing Address - Phone:210-818-8819
Mailing Address - Fax:
Practice Address - Street 1:204 W TRAILMOOR DR
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:TX
Practice Address - Zip Code:78624-3423
Practice Address - Country:US
Practice Address - Phone:210-818-8819
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-15
Last Update Date:2020-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX523751041C0700X
TX13434101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty