Provider Demographics
NPI:1417703059
Name:BODKINS, TRACI R
Entity type:Individual
Prefix:
First Name:TRACI
Middle Name:R
Last Name:BODKINS
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 1:1374 VAN VOORHIS RD LOT 24
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26505-2448
Mailing Address - Country:US
Mailing Address - Phone:304-704-6387
Mailing Address - Fax:
Practice Address - Street 1:120 PROFESSIONAL PL STE 101
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:WV
Practice Address - Zip Code:26330-4599
Practice Address - Country:US
Practice Address - Phone:304-369-8878
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-25
Last Update Date:2024-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker