Healthcare Provider Details

I. General information

NPI: 1184071789
Provider Name (Legal Business Name): BARBARA RODERICK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2016
Last Update Date: 02/16/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

41 MONTEBELLO RD SET LL1
PUEBLO CO
81001-1379
US

IV. Provider business mailing address

41 MONTEBELLO RD SUITE 200
PUEBLO CO
81001-1379
US

V. Phone/Fax

Practice location:
  • Phone: 719-545-2746
  • Fax: 719-543-7104
Mailing address:
  • Phone: 719-545-2746
  • Fax: 719-542-9638

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberACB.0007986
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: