MEDICARE: MARY BODZY PHD

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	103TC0700X	Clinical Psychologist	1665	SC

General Provider Information

NPI Number	:	1538814579
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY BODZY PHD

Provider Business Mailing Address
First Line	:	2113 MIDDLE ST STE 301
Second Line	:
City	:	SULLIVANS ISLAND
State	:	SC
Zip	:	29482-9625
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2113 MIDDLE ST STE 301
Second Line	:
City	:	SULLIVANS ISLAND
State	:	SC
Zip	:	29482-9625
Country	:	US
Telephone Number	:	843-885-8087
Fax Number	:

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

Provider Enumeration Date	:	02/17/2022
Last Update Date	:	02/17/2022

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