Healthcare Provider Details

I. General information

NPI: 1184537904
Provider Name (Legal Business Name): MACKENZIE BODNARUK
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2026
Last Update Date: 09/23/2026
Certification Date: 09/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

113 SALEM TPKE STE 10A
NORWICH CT
06360-6492
US

IV. Provider business mailing address

47 N MAIN ST
WEST HARTFORD CT
06107-1926
US

V. Phone/Fax

Practice location:
  • Phone: 860-319-0077
  • Fax: 860-319-5737
Mailing address:
  • Phone: 860-409-4595
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: