Provider Demographics
NPI:1881470607
Name:BURBANK, RODERICK STEPHEN I
Entity type:Individual
Prefix:MR
First Name:RODERICK
Middle Name:STEPHEN
Last Name:BURBANK
Suffix:I
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:49209 SONRISA ST
Mailing Address - Street 2:
Mailing Address - City:VAN BUREN TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48111-4973
Mailing Address - Country:US
Mailing Address - Phone:313-779-1120
Mailing Address - Fax:
Practice Address - Street 1:49209 SONRISA ST
Practice Address - Street 2:
Practice Address - City:VAN BUREN TWP
Practice Address - State:MI
Practice Address - Zip Code:48111-4973
Practice Address - Country:US
Practice Address - Phone:313-779-1120
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-06
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704215728163W00000X, 163WP0807X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0807XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Child & Adolescent
No163W00000XNursing Service ProvidersRegistered Nurse