Healthcare Provider Details

I. General information

NPI: 1114221405
Provider Name (Legal Business Name): STEFANIE C BODISON OTD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/01/2011
Last Update Date: 12/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1540 ALCAZAR ST CENTER FOR HEALTH PROFESSIONS (CHP) 133
LOS ANGELES CA
90089-4712
US

IV. Provider business mailing address

1540 ACAZAR CHP 133
LOS ANGELES CA
90089-0001
US

V. Phone/Fax

Practice location:
  • Phone: 310-990-3729
  • Fax:
Mailing address:
  • Phone: 310-990-3729
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number6575
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code225XF0002X
TaxonomyFeeding, Eating & Swallowing Occupational Therapist
License Number6575
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: