Basic Information
| Provider Information | |||||||||
| NPI: | 1811122849 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RODERS | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | M. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14631 NW GLACIER LN | ||||||||
| Address2: | |||||||||
| City: | BEAVERTON | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970065847 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5415173126 | ||||||||
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| Practice Location | |||||||||
| Address1: | 105 S 3RD ST | ||||||||
| Address2: | |||||||||
| City: | SAINT HELENS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970512009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5033976900 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/20/2009 | ||||||||
| LastUpdateDate: | 10/26/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | C4657 | OR | N | Behavioral Health & Social Service Providers | Counselor | Professional | 101Y00000X | Y | Behavioral Health & Social Service Providers | Counselor |
No ID Information.