Provider Demographics
NPI:1750800330
Name:RODELL, ELIZABETH KATHLEEN (ATC)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:KATHLEEN
Last Name:RODELL
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:508 S COTTAGE GROVE AVE
Mailing Address - Street 2:
Mailing Address - City:KIRKSVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63501-3341
Mailing Address - Country:US
Mailing Address - Phone:314-623-5078
Mailing Address - Fax:
Practice Address - Street 1:100 E NORMAL AVE
Practice Address - Street 2:
Practice Address - City:KIRKSVILLE
Practice Address - State:MO
Practice Address - Zip Code:63501-4200
Practice Address - Country:US
Practice Address - Phone:660-785-7521
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-14
Last Update Date:2017-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20140017392255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer