Provider Demographics
NPI:1831742568
Name:RODERICK, AIDAN N
Entity type:Individual
Prefix:
First Name:AIDAN
Middle Name:N
Last Name:RODERICK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2571 SE ELLIOTT DR
Mailing Address - Street 2:
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97080-8271
Mailing Address - Country:US
Mailing Address - Phone:541-864-0801
Mailing Address - Fax:
Practice Address - Street 1:9115 SW OLESON RD
Practice Address - Street 2:STE 100
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97223
Practice Address - Country:US
Practice Address - Phone:971-236-0915
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-22
Last Update Date:2019-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician