Provider Demographics
NPI:1245510213
Name:BODDIE, WILLIE THOMAS JR (LCSW)
Entity type:Individual
Prefix:MR
First Name:WILLIE
Middle Name:THOMAS
Last Name:BODDIE
Suffix:JR
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:306 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FRANKFORT
Mailing Address - State:KY
Mailing Address - Zip Code:40601-1895
Mailing Address - Country:US
Mailing Address - Phone:502-385-2748
Mailing Address - Fax:502-996-8400
Practice Address - Street 1:306 W MAIN ST
Practice Address - Street 2:
Practice Address - City:FRANKFORT
Practice Address - State:KY
Practice Address - Zip Code:40601-1895
Practice Address - Country:US
Practice Address - Phone:502-385-2748
Practice Address - Fax:502-996-8400
Is Sole Proprietor?:No
Enumeration Date:2011-08-23
Last Update Date:2016-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY15051041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100282590Medicaid