Healthcare Provider Details

I. General information

NPI: 1235181371
Provider Name (Legal Business Name): SANDRA CECELIA BODGE CASE MANAGER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SANDRA BODGE KAY LMHC

II. Dates (important events)

Enumeration Date: 05/17/2006
Last Update Date: 01/22/2024
Certification Date: 12/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

67 SUGAR LN
EL PRADO NM
87529
US

IV. Provider business mailing address

POB 2916
RANCHOS DE TAOS NM
87557
US

V. Phone/Fax

Practice location:
  • Phone: 575-770-2404
  • Fax:
Mailing address:
  • Phone: 505-770-2404
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberT-0096331
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: