Basic Information
| Provider Information | |||||||||
| NPI: | 1669857801 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BODAR | ||||||||
| FirstName: | BROOKE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1800 EDINBURGH ST | ||||||||
| Address2: | |||||||||
| City: | RAWLINS | ||||||||
| State: | WY | ||||||||
| PostalCode: | 823014506 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3073248820 | ||||||||
| FaxNumber: | 3073330261 | ||||||||
| Practice Location | |||||||||
| Address1: | 4989 N 3RD ST | ||||||||
| Address2: | |||||||||
| City: | LARAMIE | ||||||||
| State: | WY | ||||||||
| PostalCode: | 820729548 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3077458997 | ||||||||
| FaxNumber: | 3077426146 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/29/2015 | ||||||||
| LastUpdateDate: | 03/07/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 172V00000X | N | Other Service Providers | Community Health Worker | 101YP2500X | WY | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.