Provider Demographics
NPI:1962592790
Name:BODAN, DAYRA LILA (PSYD)
Entity type:Individual
Prefix:DR
First Name:DAYRA
Middle Name:LILA
Last Name:BODAN
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8640 SW 85TH AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33143-6930
Mailing Address - Country:US
Mailing Address - Phone:305-992-0116
Mailing Address - Fax:
Practice Address - Street 1:6501 NW 36TH ST
Practice Address - Street 2:SUITE #102
Practice Address - City:VIRGINIA GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33166-6959
Practice Address - Country:US
Practice Address - Phone:305-871-3131
Practice Address - Fax:305-871-2727
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL103TC0700X103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLZ9253AMedicare ID - Type Unspecified