Healthcare Provider Details

I. General information

NPI: 1962525287
Provider Name (Legal Business Name): HELENA A. RODERICK PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/10/2007
Last Update Date: 08/19/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

999 JAMAICA AVE NS-LIJ STUDENT HEALTH CENTER AT F.K. LANE HIGH SCHOOL
BROOKLYN NY
11208-1503
US

IV. Provider business mailing address

543 MAIN ST UNIT 308
NEW ROCHELLE NY
10801-7214
US

V. Phone/Fax

Practice location:
  • Phone: 718-235-1087
  • Fax:
Mailing address:
  • Phone: 914-819-8803
  • Fax: 718-235-1291

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number015492-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: