Provider Demographics
NPI:1538640032
Name:BODIE, DESIREE LYNN (PHYSICAL THERAPIST)
Entity Type:Individual
Prefix:
First Name:DESIREE
Middle Name:LYNN
Last Name:BODIE
Suffix:
Gender:F
Credentials:PHYSICAL THERAPIST
Other - Prefix:
Other - First Name:DESIREE
Other - Middle Name:LYNN
Other - Last Name:OLSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHYSICAL THERAPIST
Mailing Address - Street 1:5736 SKYVIEW WAY UNIT G
Mailing Address - Street 2:
Mailing Address - City:AGOURA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91301-5701
Mailing Address - Country:US
Mailing Address - Phone:818-590-2559
Mailing Address - Fax:
Practice Address - Street 1:200 PATEWOOD DR STE C150
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615-6323
Practice Address - Country:US
Practice Address - Phone:864-482-0972
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-23
Last Update Date:2018-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT21366225100000X
SC9246225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist