Provider Demographics
NPI:1144679432
Name:BODAK, AMBER DAWN (LCSW, LSW, MSW,)
Entity type:Individual
Prefix:
First Name:AMBER
Middle Name:DAWN
Last Name:BODAK
Suffix:
Gender:F
Credentials:LCSW, LSW, MSW,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8558 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:MERRILLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46410-7032
Mailing Address - Country:US
Mailing Address - Phone:219-392-7084
Mailing Address - Fax:219-703-6854
Practice Address - Street 1:800 MACARTHUR BLVD STE 5
Practice Address - Street 2:
Practice Address - City:MUNSTER
Practice Address - State:IN
Practice Address - Zip Code:46321-2917
Practice Address - Country:US
Practice Address - Phone:219-392-7025
Practice Address - Fax:219-392-7026
Is Sole Proprietor?:No
Enumeration Date:2016-06-07
Last Update Date:2023-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN33005883A104100000X
IN34007390A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300069498Medicaid