Provider Demographics
NPI:1619784345
Name:LAW, RODERICK
Entity type:Individual
Prefix:
First Name:RODERICK
Middle Name:
Last Name:LAW
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2994 BLAINE ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48206-2111
Mailing Address - Country:US
Mailing Address - Phone:313-398-4875
Mailing Address - Fax:
Practice Address - Street 1:12007 LINWOOD ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48206-1107
Practice Address - Country:US
Practice Address - Phone:313-867-1090
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-16
Last Update Date:2024-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician