Provider Demographics
NPI:1700098654
Name:BODON, DORY
Entity Type:Individual
Prefix:MISS
First Name:DORY
Middle Name:
Last Name:BODON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 30
Mailing Address - Street 2:
Mailing Address - City:GUAYNABO
Mailing Address - State:PR
Mailing Address - Zip Code:00970
Mailing Address - Country:US
Mailing Address - Phone:787-603-6006
Mailing Address - Fax:
Practice Address - Street 1:EDIF. SECTOR EL MEDIO
Practice Address - Street 2:RES. LUIS LLORENS TORRES
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00913
Practice Address - Country:US
Practice Address - Phone:787-268-1675
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-04
Last Update Date:2011-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
PR4084639103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No171M00000XOther Service ProvidersCase Manager/Care Coordinator