Healthcare Provider Details

I. General information

NPI: 1710085931
Provider Name (Legal Business Name): EMILY RODERICK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 HANNER HALL
STILLWATER OK
74078-5062
US

IV. Provider business mailing address

1305 GREYSTONE ST
STILLWATER OK
74074-1218
US

V. Phone/Fax

Practice location:
  • Phone: 405-744-6021
  • Fax: 405-744-8070
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number2295
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: