Provider Demographics
NPI:1659664696
Name:BODIN, KEVIN DALE (QMHA, CADC I)
Entity type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:DALE
Last Name:BODIN
Suffix:
Gender:M
Credentials:QMHA, CADC I
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3180 CENTER ST NE STE 2100
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-4592
Mailing Address - Country:US
Mailing Address - Phone:503-585-4949
Mailing Address - Fax:
Practice Address - Street 1:3180 CENTER ST NE STE 2100
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-4592
Practice Address - Country:US
Practice Address - Phone:503-585-4949
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-24
Last Update Date:2022-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR93-6002307171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR122994Medicaid