Provider Demographics
NPI:1417308495
Name:KANIKKEBERG, RODNEY
Entity Type:Individual
Prefix:
First Name:RODNEY
Middle Name:
Last Name:KANIKKEBERG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:317 W 6TH ST
Mailing Address - Street 2:STE 208
Mailing Address - City:MOSCOW
Mailing Address - State:ID
Mailing Address - Zip Code:83843-2321
Mailing Address - Country:US
Mailing Address - Phone:208-882-3504
Mailing Address - Fax:208-882-3572
Practice Address - Street 1:317 W 6TH ST
Practice Address - Street 2:STE 208
Practice Address - City:MOSCOW
Practice Address - State:ID
Practice Address - Zip Code:83843-2321
Practice Address - Country:US
Practice Address - Phone:208-882-3504
Practice Address - Fax:208-882-3572
Is Sole Proprietor?:No
Enumeration Date:2016-06-30
Last Update Date:2016-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLPC-6234101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health