Provider Demographics
NPI:1386069482
Name:BODNER, AMANDA
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:BODNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 GLEN COVE AVE
Mailing Address - Street 2:
Mailing Address - City:GLEN COVE
Mailing Address - State:NY
Mailing Address - Zip Code:11542-2818
Mailing Address - Country:US
Mailing Address - Phone:516-609-2000
Mailing Address - Fax:
Practice Address - Street 1:100 GLEN COVE AVE
Practice Address - Street 2:
Practice Address - City:GLEN COVE
Practice Address - State:NY
Practice Address - Zip Code:11542-2818
Practice Address - Country:US
Practice Address - Phone:516-609-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-26
Last Update Date:2018-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY091102-1104100000X
NY086691-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker