Provider Demographics
NPI:1104224161
Name:CHARLES BODNER, VIRGINIA VIRGINIA (MS OT)
Entity type:Individual
Prefix:MS
First Name:VIRGINIA
Middle Name:VIRGINIA
Last Name:CHARLES BODNER
Suffix:
Gender:F
Credentials:MS OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1986 FAIR RIDGE CT
Mailing Address - Street 2:
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94597-2929
Mailing Address - Country:US
Mailing Address - Phone:973-901-1495
Mailing Address - Fax:
Practice Address - Street 1:1986 FAIR RIDGE CT
Practice Address - Street 2:
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94597-2929
Practice Address - Country:US
Practice Address - Phone:973-901-1495
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-08
Last Update Date:2014-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14787225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist