Provider Demographics
NPI:1740737006
Name:RODERICK, JOHN C (MA,, LPC INTERN)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:C
Last Name:RODERICK
Suffix:
Gender:M
Credentials:MA,, LPC INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2073 OLYMPIC ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OR
Mailing Address - Zip Code:97477-3413
Mailing Address - Country:US
Mailing Address - Phone:541-682-3550
Mailing Address - Fax:541-682-3551
Practice Address - Street 1:101 W 5TH AVE
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-2603
Practice Address - Country:US
Practice Address - Phone:541-682-3608
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-04
Last Update Date:2017-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor