Provider Demographics
NPI:1215334123
Name:BODNAR-LARISON, CHRISTINE (LCSW)
Entity type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:
Last Name:BODNAR-LARISON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 CENTER ST
Mailing Address - Street 2:
Mailing Address - City:ELGIN
Mailing Address - State:IL
Mailing Address - Zip Code:60120-2104
Mailing Address - Country:US
Mailing Address - Phone:847-608-1344
Mailing Address - Fax:
Practice Address - Street 1:901 CENTER ST
Practice Address - Street 2:
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60120-2104
Practice Address - Country:US
Practice Address - Phone:847-608-1344
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-21
Last Update Date:2014-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0133211041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical