Provider Demographics
NPI:1982641817
Name:ROEDER, RACHAEL JEAN (AUDIOLOGIST)
Entity Type:Individual
Prefix:
First Name:RACHAEL
Middle Name:JEAN
Last Name:ROEDER
Suffix:
Gender:F
Credentials:AUDIOLOGIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:260 AINSLIE ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11211-4914
Mailing Address - Country:US
Mailing Address - Phone:718-388-1600
Mailing Address - Fax:718-388-1551
Practice Address - Street 1:360 GRAHAM AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11211-3709
Practice Address - Country:US
Practice Address - Phone:718-388-1600
Practice Address - Fax:718-388-1551
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002064-1231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY002064-1OtherNEW YORK STATE LICENSE
NY01582585Medicaid