Healthcare Provider Details

I. General information

NPI: 1255886966
Provider Name (Legal Business Name): RYAN BODINE LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2016
Last Update Date: 04/13/2021
Certification Date: 04/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28 E OLD COUNTRY RD
HICKSVILLE NY
11801-4292
US

IV. Provider business mailing address

2 S PARK DR
MASSAPEQUA NY
11758-2447
US

V. Phone/Fax

Practice location:
  • Phone: 516-519-2826
  • Fax:
Mailing address:
  • Phone: 516-519-2826
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number091020
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: