Provider Demographics
NPI:1528009651
Name:RODERICK, ROBERT SCOTT (LPC)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:SCOTT
Last Name:RODERICK
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1756 E VILLA DR STE C1
Mailing Address - Street 2:
Mailing Address - City:COTTONWOOD
Mailing Address - State:AZ
Mailing Address - Zip Code:86326-4741
Mailing Address - Country:US
Mailing Address - Phone:928-613-2093
Mailing Address - Fax:844-224-2893
Practice Address - Street 1:1756 E VILLA DR STE C1
Practice Address - Street 2:
Practice Address - City:COTTONWOOD
Practice Address - State:AZ
Practice Address - Zip Code:86326-4741
Practice Address - Country:US
Practice Address - Phone:928-613-2093
Practice Address - Fax:844-224-2893
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-09
Last Update Date:2020-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPC-10659101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ725103Medicaid