Healthcare Provider Details

I. General information

NPI: 1811813017
Provider Name (Legal Business Name): RODRICK T WILBURN JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/24/2026
Last Update Date: 06/24/2026
Certification Date: 06/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2709 4TH AVE
COLUMBUS GA
31904-8420
US

IV. Provider business mailing address

2709 4TH AVE
COLUMBUS GA
31904-8420
US

V. Phone/Fax

Practice location:
  • Phone: 706-570-6530
  • Fax:
Mailing address:
  • Phone: 706-570-6530
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number056849402
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: