Provider Demographics
NPI:1205478088
Name:TODD, RODERICK VINCENT (RECOVERY PRACTIONER)
Entity type:Individual
Prefix:MR
First Name:RODERICK
Middle Name:VINCENT
Last Name:TODD
Suffix:
Gender:M
Credentials:RECOVERY PRACTIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1873 W 54TH ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90062-2604
Mailing Address - Country:US
Mailing Address - Phone:424-440-5660
Mailing Address - Fax:310-349-3660
Practice Address - Street 1:1873 W 54TH ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90062-2604
Practice Address - Country:US
Practice Address - Phone:424-440-5660
Practice Address - Fax:310-349-3660
Is Sole Proprietor?:No
Enumeration Date:2019-10-12
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YM0800X, 104100000X, 171M00000X, 172A00000X, 175T00000X, 222Q00000X, 225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No172A00000XOther Service ProvidersDriver
No175T00000XOther Service ProvidersPeer Specialist
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA812735555Medicaid