MEDICARE: LORI RODABOUGH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician	BACB1176934	WY

General Provider Information

NPI Number	:	1851125611
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LORI RODABOUGH

Provider Business Mailing Address
First Line	:	PO BOX 20310
Second Line	:
City	:	CHEYENNE
State	:	WY
Zip	:	82003-7007
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	79 WINSTON DR
Second Line	:
City	:	ROCK SPRINGS
State	:	WY
Zip	:	82901-5768
Country	:	US
Telephone Number	:	307-212-3284
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/26/2024
Last Update Date	:	08/26/2024

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Directions to “ LORI RODABOUGH ” Practice Location

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