Provider Demographics
NPI:1881745206
Name:BODINE, TRACY (LCSW)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:BODINE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 DAY HILL RD
Mailing Address - Street 2:
Mailing Address - City:WINDSOR
Mailing Address - State:CT
Mailing Address - Zip Code:06095-1707
Mailing Address - Country:US
Mailing Address - Phone:860-925-6052
Mailing Address - Fax:860-925-6054
Practice Address - Street 1:110 DAY HILL RD
Practice Address - Street 2:
Practice Address - City:WINDSOR
Practice Address - State:CT
Practice Address - Zip Code:06095-1707
Practice Address - Country:US
Practice Address - Phone:860-925-6052
Practice Address - Fax:860-925-6054
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-13
Last Update Date:2014-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0012521041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT800000720Medicare PIN