Provider Demographics
NPI:1528006368
Name:ROEDIGER, KERRY ANNE (SLP)
Entity Type:Individual
Prefix:
First Name:KERRY
Middle Name:ANNE
Last Name:ROEDIGER
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1722 NW RALEIGH ST
Mailing Address - Street 2:SUITE 318
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97209-1753
Mailing Address - Country:US
Mailing Address - Phone:503-224-2820
Mailing Address - Fax:503-224-2607
Practice Address - Street 1:1722 NW RALEIGH ST
Practice Address - Street 2:SUITE 318
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97209-1753
Practice Address - Country:US
Practice Address - Phone:503-224-2820
Practice Address - Fax:503-224-2607
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-03
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALL00003688235Z00000X
OR12293235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
09138419OtherASHA CERTIFICATION - SLP
OR182755Medicaid
OR12293OtherOREGON LICENSE - SLP
WA7131154Medicaid
WALL00003688OtherWAHINGTON LICENSE - SLP