Provider Demographics
NPI:1932140779
Name:RODENBOUGH, JOHN RYAN (PSYD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:RYAN
Last Name:RODENBOUGH
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 N ELM ST
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27401-1004
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1126 N CHURCH ST STE 103
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27401-1035
Practice Address - Country:US
Practice Address - Phone:336-663-4900
Practice Address - Fax:336-663-4920
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-10
Last Update Date:2021-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2257103TC0700X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0405VOtherBCBS NC
NC5857267OtherAETNA
NCB5701OtherMEDCOST
NCB5701OtherMEDCOST
NC6000282Medicaid