Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 225X00000X | Occupational Therapist | 31004003A | IN |
Y | 225XH1200X | Occupational Therapist - Hand | 31004003A | IN |
NPI | 1124212501 |
---|---|
Provider Name | Jody Lee Lee |
First Address | Indianapolis, IN 46260-2046 |
Second Address | Indianapolis, IN 46260-2046 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 29/08/2007 |
Last Update Date | 20/12/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
000000765889 | ANTHEM PROVIDER NUMBER (01) | IN |
200504740 | (05) | IN |