Provider Demographics
NPI:1023310331
Name:WILLIAMS, RODEREICK BERNARD (OTR/L)
Entity type:Individual
Prefix:MR
First Name:RODEREICK
Middle Name:BERNARD
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36401 MANCHAC CROSSING
Mailing Address - Street 2:
Mailing Address - City:PRAIRIEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70769
Mailing Address - Country:US
Mailing Address - Phone:225-405-4066
Mailing Address - Fax:225-677-8468
Practice Address - Street 1:36401 MANCHAC CROSSING
Practice Address - Street 2:
Practice Address - City:PRAIRIEVILLE
Practice Address - State:LA
Practice Address - Zip Code:70769
Practice Address - Country:US
Practice Address - Phone:225-405-4066
Practice Address - Fax:225-677-8468
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-19
Last Update Date:2013-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAOTT.Z11008225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAOTT.Z11008OtherOCCUPATIONAL THERAPIST