Provider Demographics
NPI:1164953659
Name:BRODIE, AIDAN MARTIN (COTA)
Entity Type:Individual
Prefix:MR
First Name:AIDAN
Middle Name:MARTIN
Last Name:BRODIE
Suffix:
Gender:M
Credentials:COTA
Other - Prefix:MR
Other - First Name:AIDAN
Other - Middle Name:MARTIN
Other - Last Name:BRODIE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:COTA
Mailing Address - Street 1:10325 KERRY RIDGE CT
Mailing Address - Street 2:
Mailing Address - City:CHICAGO RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60415-2390
Mailing Address - Country:US
Mailing Address - Phone:708-655-3179
Mailing Address - Fax:
Practice Address - Street 1:10325 KERRY RIDGE CT
Practice Address - Street 2:
Practice Address - City:CHICAGO RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60415-2390
Practice Address - Country:US
Practice Address - Phone:708-655-3179
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-25
Last Update Date:2017-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL057.004681224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant