Provider Demographics
NPI:1831316082
Name:RODERICK, STACEY LYNN (PTA)
Entity type:Individual
Prefix:MS
First Name:STACEY
Middle Name:LYNN
Last Name:RODERICK
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:854 DORCHESTER AVE
Mailing Address - Street 2:UNIT#1
Mailing Address - City:DORCHESTER
Mailing Address - State:MA
Mailing Address - Zip Code:02125-1133
Mailing Address - Country:US
Mailing Address - Phone:617-265-3735
Mailing Address - Fax:
Practice Address - Street 1:854 DORCHESTER AVE
Practice Address - Street 2:UNIT#1
Practice Address - City:DORCHESTER
Practice Address - State:MA
Practice Address - Zip Code:02125-1133
Practice Address - Country:US
Practice Address - Phone:617-265-3735
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3716225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant