Healthcare Provider Details

I. General information

NPI: 1811122849
Provider Name (Legal Business Name): KENNETH M. RODERS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2009
Last Update Date: 10/26/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 S 3RD ST
SAINT HELENS OR
97051-2009
US

IV. Provider business mailing address

14631 NW GLACIER LN
BEAVERTON OR
97006-5847
US

V. Phone/Fax

Practice location:
  • Phone: 503-397-6900
  • Fax:
Mailing address:
  • Phone: 541-517-3126
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberC4657
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: