MEDICARE: TAMMIE BODNER LMSW, ACSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	101569	CA
2	1041C0700X	Clinical Social Worker	09004014383	VA
3	1041C0700X	Clinical Social Worker	6801086551	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	123456	OTHER		I DO NOT HAVE THIS INFORMATION

General Provider Information

NPI Number	:	1265777031
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TAMMIE BODNER LMSW, ACSW

Provider Business Mailing Address
First Line	:	2700 W EL CAMINO REAL APT 238
Second Line	:
City	:	MOUNTAIN VIEW
State	:	CA
Zip	:	94040-2894
Country	:	US
Telephone Number	:	414-399-6122
Fax Number	:

Provider Business Practice Location Address
First Line	:	2700 W EL CAMINO REAL APT 238
Second Line	:
City	:	MOUNTAIN VIEW
State	:	CA
Zip	:	94040-2894
Country	:	US
Telephone Number	:	414-399-6122
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/05/2012
Last Update Date	:	01/24/2023

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