1528006368 NPI number — KERRY ANNE ROEDIGER SLP

Table of content: KERRY ANNE ROEDIGER SLP (NPI 1528006368)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528006368 NPI number — KERRY ANNE ROEDIGER SLP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROEDIGER
Provider First Name:
KERRY
Provider Middle Name:
ANNE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
SLP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1528006368
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1722 NW RALEIGH ST
Provider Second Line Business Mailing Address:
SUITE 318
Provider Business Mailing Address City Name:
PORTLAND
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97209-1753
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-224-2820
Provider Business Mailing Address Fax Number:
503-224-2607

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1722 NW RALEIGH ST
Provider Second Line Business Practice Location Address:
SUITE 318
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97209-1753
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-224-2820
Provider Business Practice Location Address Fax Number:
503-224-2607
Provider Enumeration Date:
06/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 235Z00000X , with the licence number:  LL00003688 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 235Z00000X , with the licence number: 12293 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 09138419 . This is a "ASHA CERTIFICATION - SLP" identifier . This identifiers is of the category "OTHER".
  • Identifier: 182755 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 12293 . This is a "OREGON LICENSE - SLP" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 7131154 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: LL00003688 . This is a "WAHINGTON LICENSE - SLP" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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