Healthcare Provider Details

I. General information

NPI: 1851385546
Provider Name (Legal Business Name): STANLEY BODNER PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/08/2005
Last Update Date: 05/07/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1579 E 29TH ST
BROOKLYN NY
11229-1846
US

IV. Provider business mailing address

1579 E 29TH ST
BROOKLYN NY
11229-1846
US

V. Phone/Fax

Practice location:
  • Phone: 718-339-4916
  • Fax: 718-339-5997
Mailing address:
  • Phone: 718-339-4916
  • Fax: 718-339-5997

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number6557-1
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number6557-1
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number6557-1
License Number StateNY
# 4
Primary TaxonomyN
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number6557-1
License Number StateNY
# 5
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number6557-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: