Provider Demographics
NPI:1225175599
Name:RODDICK, REBECCA SUE (OTRL)
Entity Type:Individual
Prefix:MISS
First Name:REBECCA
Middle Name:SUE
Last Name:RODDICK
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:681 PHEASANT RUN
Mailing Address - Street 2:
Mailing Address - City:SHERMAN
Mailing Address - State:IL
Mailing Address - Zip Code:62684-9583
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:701 N 1ST ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62781-0001
Practice Address - Country:US
Practice Address - Phone:217-788-3300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2015-07-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL56006690OtherOCCUPATIONAL THERAPIST