Provider Demographics
NPI:1215795331
Name:BODEMAN, TAD (LCSW)
Entity type:Individual
Prefix:
First Name:TAD
Middle Name:
Last Name:BODEMAN
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 GRANDVIEW BLVD
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:TX
Mailing Address - Zip Code:77356-4004
Mailing Address - Country:US
Mailing Address - Phone:832-221-7075
Mailing Address - Fax:
Practice Address - Street 1:900 LOVETT BLVD
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77006-3908
Practice Address - Country:US
Practice Address - Phone:713-470-9878
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-12
Last Update Date:2024-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX663711041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical