Provider Demographics
NPI:1629613013
Name:ROBERTSON, JODY LEE (COTA/L)
Entity Type:Individual
Prefix:
First Name:JODY
Middle Name:LEE
Last Name:ROBERTSON
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1580 PERDIDO CT
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32940-6226
Mailing Address - Country:US
Mailing Address - Phone:218-780-1991
Mailing Address - Fax:
Practice Address - Street 1:2040 HIGHWAY A1A STE 203
Practice Address - Street 2:
Practice Address - City:INDIAN HARBOUR BEACH
Practice Address - State:FL
Practice Address - Zip Code:32937-3566
Practice Address - Country:US
Practice Address - Phone:321-773-8989
Practice Address - Fax:321-773-7999
Is Sole Proprietor?:No
Enumeration Date:2019-11-09
Last Update Date:2019-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA17461224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant