Provider Demographics
NPI:1023074739
Name:RODNICK, CHERYL E (OTR L, CHT)
Entity type:Individual
Prefix:MRS
First Name:CHERYL
Middle Name:E
Last Name:RODNICK
Suffix:
Gender:F
Credentials:OTR L, CHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1950 E CLARK ST
Mailing Address - Street 2:STF
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-3314
Mailing Address - Country:US
Mailing Address - Phone:208-232-2519
Mailing Address - Fax:208-232-5553
Practice Address - Street 1:1950 E CLARK ST
Practice Address - Street 2:STF
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-3314
Practice Address - Country:US
Practice Address - Phone:208-232-2915
Practice Address - Fax:208-232-5553
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDOT-209225XH1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010023189OtherREGENCE OF ID
IDW0533OtherBLUE CROSS
ID1655078Medicare PIN