Provider Demographics
NPI:1831644624
Name:RODDEWIG, RODNEY WG
Entity Type:Individual
Prefix:
First Name:RODNEY
Middle Name:WG
Last Name:RODDEWIG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 S ELLSWORTH AVE APT 106
Mailing Address - Street 2:
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94401-4076
Mailing Address - Country:US
Mailing Address - Phone:650-393-0933
Mailing Address - Fax:
Practice Address - Street 1:205 S ELLSWORTH AVE APT 106
Practice Address - Street 2:
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94401-4076
Practice Address - Country:US
Practice Address - Phone:650-393-0933
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-22
Last Update Date:2016-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker