Provider Demographics
NPI:1699490938
Name:BODNER, KAYLEE A (LCSW-A, LCAS-A)
Entity type:Individual
Prefix:
First Name:KAYLEE
Middle Name:A
Last Name:BODNER
Suffix:
Gender:F
Credentials:LCSW-A, LCAS-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2705 HAVERFORD PL APT 416
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28209-1415
Mailing Address - Country:US
Mailing Address - Phone:704-999-0670
Mailing Address - Fax:
Practice Address - Street 1:120 S VILLAGE LN STE D
Practice Address - Street 2:
Practice Address - City:DAVIDSON
Practice Address - State:NC
Practice Address - Zip Code:28036-8159
Practice Address - Country:US
Practice Address - Phone:704-255-5155
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-10
Last Update Date:2022-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLCAS-28128101YA0400X
NCP0177551041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)