Provider Demographics
NPI:1457474736
Name:KODISH, RONNIE M
Entity Type:Individual
Prefix:
First Name:RONNIE
Middle Name:M
Last Name:KODISH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1645 RIVER BIRCH AVE
Mailing Address - Street 2:
Mailing Address - City:OVIEDO
Mailing Address - State:FL
Mailing Address - Zip Code:32765-7963
Mailing Address - Country:US
Mailing Address - Phone:708-362-1028
Mailing Address - Fax:
Practice Address - Street 1:1645 RIVER BIRCH AVE
Practice Address - Street 2:
Practice Address - City:OVIEDO
Practice Address - State:FL
Practice Address - Zip Code:32765-7963
Practice Address - Country:US
Practice Address - Phone:708-362-1028
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-09
Last Update Date:2020-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist