Healthcare Provider Details

I. General information

NPI: 1225693732
Provider Name (Legal Business Name): AMANDA ASHLEY BODENDORF MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/09/2019
Last Update Date: 05/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

939 JOHNSON AVE
RONKONKOMA NY
11779-6066
US

IV. Provider business mailing address

140 JAYNE AVE
PATCHOGUE NY
11772-2835
US

V. Phone/Fax

Practice location:
  • Phone: 631-471-7242
  • Fax:
Mailing address:
  • Phone: 631-901-4244
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number106441-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: