Provider Demographics
NPI:1679746846
Name:RODEBACK, DAVID EDMAND (PHD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:EDMAND
Last Name:RODEBACK
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 1:1121 E 3900 S STE C230
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84124-1297
Mailing Address - Country:US
Mailing Address - Phone:801-266-0878
Mailing Address - Fax:
Practice Address - Street 1:3838 S 700 E STE 100
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84106-1494
Practice Address - Country:US
Practice Address - Phone:801-269-0231
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-09
Last Update Date:2020-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT138978 3501104100000X
UT138978-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker