Basic Information
| Provider Information | |||||||||
| NPI: | 1255945408 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BODLAK | ||||||||
| FirstName: | TARA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 840 PARK AVE APT 204 | ||||||||
| Address2: | |||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681052133 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 2101 S 42ND ST | ||||||||
| Address2: | |||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681052909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4025533000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/04/2020 | ||||||||
| LastUpdateDate: | 09/04/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/04/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 7516 | NE | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 101Y00000X | 12330 | NE | Y | Behavioral Health & Social Service Providers | Counselor |
No ID Information.