Healthcare Provider Details

I. General information

NPI: 1386550226
Provider Name (Legal Business Name): VANESSA LEE RODERICK MS, CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/20/2026
Last Update Date: 08/20/2026
Certification Date: 08/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2875 HOLLY DR
TRACY CA
95376-2170
US

IV. Provider business mailing address

615 DUPONT DR
STOCKTON CA
95210-2013
US

V. Phone/Fax

Practice location:
  • Phone: 209-830-3270
  • Fax:
Mailing address:
  • Phone: 510-302-8187
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number29622
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: