Provider Demographics
NPI:1548369390
Name:BODWALK, MARK A (LPC LMFT)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:A
Last Name:BODWALK
Suffix:
Gender:M
Credentials:LPC LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6922 NEWMAN RD
Mailing Address - Street 2:
Mailing Address - City:CLIFTON
Mailing Address - State:VA
Mailing Address - Zip Code:20124-1613
Mailing Address - Country:US
Mailing Address - Phone:703-830-8864
Mailing Address - Fax:703-830-8864
Practice Address - Street 1:6922 NEWMAN RD
Practice Address - Street 2:
Practice Address - City:CLIFTON
Practice Address - State:VA
Practice Address - Zip Code:20112-1613
Practice Address - Country:US
Practice Address - Phone:703-830-8864
Practice Address - Fax:703-830-8864
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701002569101YP2500X
VA0717000297106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist