Provider Demographics
NPI:1164100475
Name:RODAMAKER, KACY
Entity Type:Individual
Prefix:
First Name:KACY
Middle Name:
Last Name:RODAMAKER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1651 N 400 E APT 331
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84341-5649
Mailing Address - Country:US
Mailing Address - Phone:612-619-2350
Mailing Address - Fax:
Practice Address - Street 1:6405 OLD MAIN HILL
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84322-0001
Practice Address - Country:US
Practice Address - Phone:435-797-4200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-06
Last Update Date:2023-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician