Provider Demographics
NPI:1255620506
Name:BODELL, DAWN MARIE (PT)
Entity type:Individual
Prefix:
First Name:DAWN
Middle Name:MARIE
Last Name:BODELL
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7425 MISSION VALLEY RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108-4409
Mailing Address - Country:US
Mailing Address - Phone:619-291-3400
Mailing Address - Fax:
Practice Address - Street 1:34800 BOB WILSON DR FL 1
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92134-4409
Practice Address - Country:US
Practice Address - Phone:619-532-6328
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-06
Last Update Date:2024-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA377112251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGE297ZMedicare PIN
CAW17215Medicare PIN