Provider Demographics
NPI:1689302648
Name:BRODUS, ARIEL JAMAL (COTA)
Entity Type:Individual
Prefix:MR
First Name:ARIEL
Middle Name:JAMAL
Last Name:BRODUS
Suffix:
Gender:M
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 RIDGECREST LOOP APT B
Mailing Address - Street 2:
Mailing Address - City:MINNEOLA
Mailing Address - State:FL
Mailing Address - Zip Code:34715-5553
Mailing Address - Country:US
Mailing Address - Phone:352-255-1801
Mailing Address - Fax:
Practice Address - Street 1:365 CITRUS TOWER BLVD
Practice Address - Street 2:
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34711-6532
Practice Address - Country:US
Practice Address - Phone:321-276-5054
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-09
Last Update Date:2022-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL18963224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant