Provider Demographics
NPI:1124212501
Name:LEE, JODY LEE (MS, OTR)
Entity Type:Individual
Prefix:
First Name:JODY
Middle Name:LEE
Last Name:LEE
Suffix:
Gender:F
Credentials:MS, OTR
Other - Prefix:
Other - First Name:JODY
Other - Middle Name:LEE
Other - Last Name:BEAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8501 HARCOURT RD
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46260-2046
Mailing Address - Country:US
Mailing Address - Phone:317-872-5101
Mailing Address - Fax:317-875-9174
Practice Address - Street 1:8501 HARCOURT RD
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46260-2046
Practice Address - Country:US
Practice Address - Phone:317-872-5101
Practice Address - Fax:317-875-9174
Is Sole Proprietor?:No
Enumeration Date:2007-08-29
Last Update Date:2012-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN31004003A225X00000X, 225XH1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200504740Medicaid
IN000000765889OtherANTHEM PROVIDER NUMBER
INM400069120Medicare PIN
IN200504740Medicaid