Provider Demographics
NPI:1417612169
Name:RODERICK, MARISSA JANE (OT)
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:JANE
Last Name:RODERICK
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 12TH AVE W STE 2A
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA FALLS
Mailing Address - State:MT
Mailing Address - Zip Code:59912-3855
Mailing Address - Country:US
Mailing Address - Phone:406-471-1117
Mailing Address - Fax:406-309-2076
Practice Address - Street 1:55 HERITAGE WAY
Practice Address - Street 2:
Practice Address - City:KALISPELL
Practice Address - State:MT
Practice Address - Zip Code:59901-3100
Practice Address - Country:US
Practice Address - Phone:406-471-9910
Practice Address - Fax:406-309-2076
Is Sole Proprietor?:No
Enumeration Date:2021-11-07
Last Update Date:2022-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0007132225X00000X
MT9466225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist