Healthcare Provider Details

I. General information

NPI: 1093168106
Provider Name (Legal Business Name): ZACHARY BODENWEBER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2016
Last Update Date: 07/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 CRUM ELBOW RD
HYDE PARK NY
12538-2852
US

IV. Provider business mailing address

63 FLORENCE ST
KINGSTON NY
12401-3017
US

V. Phone/Fax

Practice location:
  • Phone: 845-229-2005
  • Fax:
Mailing address:
  • Phone: 845-389-2016
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberP02613
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: