Provider Demographics
NPI:1023594355
Name:ZIMMER, CODY REESE (OTD, OTR/L)
Entity type:Individual
Prefix:
First Name:CODY
Middle Name:REESE
Last Name:ZIMMER
Suffix:
Gender:M
Credentials:OTD, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:525 W 500 N
Mailing Address - Street 2:
Mailing Address - City:PERU
Mailing Address - State:IN
Mailing Address - Zip Code:46970-8637
Mailing Address - Country:US
Mailing Address - Phone:765-226-0471
Mailing Address - Fax:
Practice Address - Street 1:300 E WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46802-3124
Practice Address - Country:US
Practice Address - Phone:260-422-5511
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-19
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN31006637A225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist