Basic Information
| Provider Information | |||||||||
| NPI: | 1073796900 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BODKIN | ||||||||
| FirstName: | LESLIE | ||||||||
| MiddleName: | JANE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MS, OTR/L, CEIS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 61 MEDFORD ST | ||||||||
| Address2: | |||||||||
| City: | SOMERVILLE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021433421 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6176293919 | ||||||||
| FaxNumber: | 6176294644 | ||||||||
| Practice Location | |||||||||
| Address1: | 61 MEDFORD ST | ||||||||
| Address2: | |||||||||
| City: | SOMERVILLE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021433421 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6176293919 | ||||||||
| FaxNumber: | 6176294644 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/13/2007 | ||||||||
| LastUpdateDate: | 12/13/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | AH6913-OT | MA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.