Provider Demographics
NPI:1528003142
Name:RODWICK, JOHN R (PHD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:R
Last Name:RODWICK
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4300 REAL DEL SUR
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88011-7205
Mailing Address - Country:US
Mailing Address - Phone:505-647-2884
Mailing Address - Fax:
Practice Address - Street 1:100 W GRIGGS AVE
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88001-1234
Practice Address - Country:US
Practice Address - Phone:505-647-2800
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM82171101YM0800X
CO1241103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist