Healthcare Provider Details

I. General information

NPI: 1174246466
Provider Name (Legal Business Name): MARIE CLAIRE RODERICK PSYD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/21/2022
Last Update Date: 10/17/2022
Certification Date: 10/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12591 WHIPPOORWILL ST
BROOMFIELD CO
80020-7919
US

IV. Provider business mailing address

PO BOX 756
BROOMFIELD CO
80038-0756
US

V. Phone/Fax

Practice location:
  • Phone: 571-276-8939
  • Fax:
Mailing address:
  • Phone: 571-234-8106
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. MARIE CLAIRE RODERICK
Title or Position: CLINICAL PSYCHOLOGIST
Credential: PSYD
Phone: 571-234-8106