Provider Demographics
NPI:1831894963
Name:THE BODHI TREE, A LICENSED CLINICAL SOCIAL WORKER CORP
Entity type:Organization
Organization Name:THE BODHI TREE, A LICENSED CLINICAL SOCIAL WORKER CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/LEAD THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:BRAD
Authorized Official - Middle Name:K
Authorized Official - Last Name:NYMAN
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:949-294-8627
Mailing Address - Street 1:7355 CHURCH ST STE A
Mailing Address - Street 2:
Mailing Address - City:YUCCA VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92284-3273
Mailing Address - Country:US
Mailing Address - Phone:760-517-3377
Mailing Address - Fax:760-517-3377
Practice Address - Street 1:7355 CHURCH ST STE A
Practice Address - Street 2:
Practice Address - City:YUCCA VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92284-3273
Practice Address - Country:US
Practice Address - Phone:760-517-3377
Practice Address - Fax:760-517-3377
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-30
Last Update Date:2023-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty