Healthcare Provider Details

I. General information

NPI: 1144679432
Provider Name (Legal Business Name): AMBER DAWN BODAK LCSW, LSW, MSW,
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2016
Last Update Date: 01/19/2023
Certification Date: 01/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 MACARTHUR BLVD STE 5
MUNSTER IN
46321-2917
US

IV. Provider business mailing address

8558 BROADWAY
MERRILLVILLE IN
46410-7032
US

V. Phone/Fax

Practice location:
  • Phone: 219-392-7025
  • Fax: 219-392-7026
Mailing address:
  • Phone: 219-392-7084
  • Fax: 219-703-6854

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number33005883A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number34007390A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: