Provider Demographics
NPI:1851750376
Name:RODERICK, MARIE CLAIRE (PSYD)
Entity Type:Individual
Prefix:DR
First Name:MARIE CLAIRE
Middle Name:
Last Name:RODERICK
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:280 E 1ST AVE
Mailing Address - Street 2:
Mailing Address - City:BROOMFIELD
Mailing Address - State:CO
Mailing Address - Zip Code:80020-2438
Mailing Address - Country:US
Mailing Address - Phone:571-234-8106
Mailing Address - Fax:
Practice Address - Street 1:12591 WHIPPOORWILL ST
Practice Address - Street 2:
Practice Address - City:BROOMFIELD
Practice Address - State:CO
Practice Address - Zip Code:80020-7919
Practice Address - Country:US
Practice Address - Phone:571-276-8939
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-11
Last Update Date:2022-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810005301103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO0005553OtherCOLORADO LICENSE NUMBER
VA0810005301OtherVA STATE LICENSURE NUMBER