MEDICARE: MARISSA BODNER LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	CSW.09926485	CO

General Provider Information

NPI Number	:	1528694981
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARISSA BODNER LCSW

Provider Business Mailing Address
First Line	:	12954 W ILIFF AVE
Second Line	:
City	:	LAKEWOOD
State	:	CO
Zip	:	80228-4335
Country	:	US
Telephone Number	:	303-954-4052
Fax Number	:	303-504-6410

Provider Business Practice Location Address
First Line	:	1490 N LAFAYETTE ST
Second Line	:	SUITE 108
City	:	DENVER
State	:	CO
Zip	:	80218-2391
Country	:	US
Telephone Number	:	303-954-4052
Fax Number	:	303-504-6410

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/18/2020
Last Update Date	:	03/18/2020

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Directions to “ MARISSA BODNER LCSW” Practice Location

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