Healthcare Provider Details

I. General information

NPI: 1770041337
Provider Name (Legal Business Name): MISS CASSANDRA LYNN BODNAR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/03/2019
Last Update Date: 06/05/2020
Certification Date: 06/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2035 S 4TH ST
PHILADELPHIA PA
19148-2550
US

IV. Provider business mailing address

5211 SENTINEL RDG
NORRISTOWN PA
19403-5275
US

V. Phone/Fax

Practice location:
  • Phone: 312-965-2997
  • Fax:
Mailing address:
  • Phone: 215-756-7218
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: