Provider Demographics
NPI:1649308248
Name:BODE, M REBECCA (PHD)
Entity type:Individual
Prefix:DR
First Name:M
Middle Name:REBECCA
Last Name:BODE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9002 FAIRMOUNT RD
Mailing Address - Street 2:
Mailing Address - City:NOVELTY
Mailing Address - State:OH
Mailing Address - Zip Code:44072-9777
Mailing Address - Country:US
Mailing Address - Phone:440-338-1538
Mailing Address - Fax:440-338-1538
Practice Address - Street 1:9002 FAIRMOUNT RD
Practice Address - Street 2:
Practice Address - City:NOVELTY
Practice Address - State:OH
Practice Address - Zip Code:44072-9777
Practice Address - Country:US
Practice Address - Phone:440-338-1538
Practice Address - Fax:440-338-1538
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4330103T00000X, 103TB0200X, 103TC2200X, 103TE1100X, 103TM1800X, 103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Not Answered103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
Not Answered103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Not Answered103TE1100XBehavioral Health & Social Service ProvidersPsychologistExercise & Sports
Not Answered103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities
Not Answered103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool