Healthcare Provider Details

I. General information

NPI: 1497989537
Provider Name (Legal Business Name): TRAVIS D RODERICK
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/04/2009
Last Update Date: 05/04/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1790 W 11TH AVE STE 290
EUGENE OR
97402-3758
US

IV. Provider business mailing address

3255 GATEWAY ST APT. 31
SPRINGFIELD OR
97477-1053
US

V. Phone/Fax

Practice location:
  • Phone: 541-686-1262
  • Fax:
Mailing address:
  • Phone: 541-510-4051
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: