Healthcare Provider Details

I. General information

NPI: 1780871236
Provider Name (Legal Business Name): RODERICK EDWARD THEIS II MSW, LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2007
Last Update Date: 09/28/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

622 AIRPORT RD
PENDLETON OR
97801-4598
US

IV. Provider business mailing address

622 AIRPORT RD
PENDLETON OR
97801-4598
US

V. Phone/Fax

Practice location:
  • Phone: 541-276-0057
  • Fax: 541-276-1704
Mailing address:
  • Phone: 541-276-0057
  • Fax: 541-276-1704

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberL4084
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: