Provider Demographics
NPI:1124336763
Name:JODHARAM, REENA (COTA/L)
Entity type:Individual
Prefix:
First Name:REENA
Middle Name:
Last Name:JODHARAM
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 1:513 SW HIAWATHA ST
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34953-6275
Mailing Address - Country:US
Mailing Address - Phone:772-621-8798
Mailing Address - Fax:
Practice Address - Street 1:513 SW HIAWATHA ST
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34953
Practice Address - Country:US
Practice Address - Phone:772-621-8798
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-16
Last Update Date:2010-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA10182224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant