Provider Demographics
NPI:1639534399
Name:BODINE, STACY
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:BODINE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38 REVOLUTION WAY APT 112
Mailing Address - Street 2:
Mailing Address - City:EWING
Mailing Address - State:NJ
Mailing Address - Zip Code:08628-1940
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3401 PRINCETON PIKE
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08648-1205
Practice Address - Country:US
Practice Address - Phone:609-203-1642
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-23
Last Update Date:2025-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL390200000X
NJ25MT003120002255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program