MEDICARE: MS. JANESSA ELISE BODZON 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	007824	CT

General Provider Information

NPI Number	:	1891067641
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. JANESSA ELISE BODZON LCSW

Provider Business Mailing Address
First Line	:	12 FRENCH ST
Second Line	:
City	:	SEYMOUR
State	:	CT
Zip	:	06483-3021
Country	:	US
Telephone Number	:	203-494-1720
Fax Number	:

Provider Business Practice Location Address
First Line	:	225 N MAIN ST STE 106
Second Line	:
City	:	BRISTOL
State	:	CT
Zip	:	06010-4993
Country	:	US
Telephone Number	:	860-585-4300
Fax Number	:

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

Provider Enumeration Date	:	02/08/2012
Last Update Date	:	02/08/2012

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