Provider Demographics
NPI:1528791415
Name:COGDILL, JOHN DEREK (OT)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:DEREK
Last Name:COGDILL
Suffix:
Gender:M
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:309 PLANTATION DR
Mailing Address - Street 2:
Mailing Address - City:LAKE JACKSON
Mailing Address - State:TX
Mailing Address - Zip Code:77566-6142
Mailing Address - Country:US
Mailing Address - Phone:979-418-7165
Mailing Address - Fax:800-419-5153
Practice Address - Street 1:309 PLANTATION DR
Practice Address - Street 2:
Practice Address - City:LAKE JACKSON
Practice Address - State:TX
Practice Address - Zip Code:77566-6142
Practice Address - Country:US
Practice Address - Phone:979-418-7165
Practice Address - Fax:800-419-5153
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-07
Last Update Date:2022-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX212525224Z00000X
TX122982225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant