=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023356243
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RODERICK BOHANAN JEFFERS LMHC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/23/2013
-----------------------------------------------------
Last Update Date | 10/11/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4194 BOLIVAR RD
-----------------------------------------------------
City | WELLSVILLE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14895-9325
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 585-665-2623
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 23 WITTER AVE
-----------------------------------------------------
City | WELLSVILLE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14895-1331
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 585-665-2623
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------