Healthcare Provider Details

I. General information

NPI: 1962217489
Provider Name (Legal Business Name): DAVID EDWIN RODDENBERRY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/11/2025
Last Update Date: 03/04/2025
Certification Date: 03/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 NATURE WALK PKWY UNIT 104
SAINT AUGUSTINE FL
32092-5065
US

IV. Provider business mailing address

24 SEAHILL DR
SAINT AUGUSTINE FL
32092-1112
US

V. Phone/Fax

Practice location:
  • Phone: 407-748-0982
  • Fax:
Mailing address:
  • Phone: 407-748-0982
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH25268
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: