Provider Demographics
NPI:1891042503
Name:BODI, JEREMIAH ALLEN (COTA/L)
Entity Type:Individual
Prefix:
First Name:JEREMIAH
Middle Name:ALLEN
Last Name:BODI
Suffix:
Gender:M
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 1:148 WILSON ST
Mailing Address - Street 2:
Mailing Address - City:DEFIANCE
Mailing Address - State:OH
Mailing Address - Zip Code:43512-1440
Mailing Address - Country:US
Mailing Address - Phone:419-956-1612
Mailing Address - Fax:
Practice Address - Street 1:303 N HURSTBOURNE PKWY STE 200
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40222-5158
Practice Address - Country:US
Practice Address - Phone:502-412-5847
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-13
Last Update Date:2012-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOTA 04970224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant