Provider Demographics
NPI:1043612955
Name:HODGE, HALEY
Entity Type:Individual
Prefix:MRS
First Name:HALEY
Middle Name:
Last Name:HODGE
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:HALEY
Other - Middle Name:
Other - Last Name:BORNEMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MOT, OTR/L
Mailing Address - Street 1:4819 CHASTAIN DR
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32940-1277
Mailing Address - Country:US
Mailing Address - Phone:321-298-9775
Mailing Address - Fax:
Practice Address - Street 1:4819 CHASTAIN DR
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32940-1277
Practice Address - Country:US
Practice Address - Phone:321-298-9775
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-23
Last Update Date:2024-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL225X00000X
FLOTA 11471224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist