Provider Demographics
NPI:1679893515
Name:RODERICK, COREY ALLEN (MA, MOT, OTR/L)
Entity Type:Individual
Prefix:
First Name:COREY
Middle Name:ALLEN
Last Name:RODERICK
Suffix:
Gender:M
Credentials:MA, MOT, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:315 S FOREST ST
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80246-8107
Mailing Address - Country:US
Mailing Address - Phone:765-585-5542
Mailing Address - Fax:
Practice Address - Street 1:315 S FOREST ST
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80246-8107
Practice Address - Country:US
Practice Address - Phone:765-585-5542
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-02
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
N/A171M00000X
COOT.0004808225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No171M00000XOther Service ProvidersCase Manager/Care Coordinator