Provider Demographics
NPI:1568534899
Name:RODER, GEORGETTE RIERA (ITDS)
Entity Type:Individual
Prefix:MS
First Name:GEORGETTE
Middle Name:RIERA
Last Name:RODER
Suffix:
Gender:F
Credentials:ITDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 N.E. 195 STREET
Mailing Address - Street 2:613
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33179-3439
Mailing Address - Country:US
Mailing Address - Phone:786-246-0268
Mailing Address - Fax:305-653-7189
Practice Address - Street 1:1601 NW 12TH AVE STE 206
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33136-1005
Practice Address - Country:US
Practice Address - Phone:305-243-6660
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2019-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
No103T00000XBehavioral Health & Social Service ProvidersPsychologist