Provider Demographics
NPI:1104544303
Name:MATHESON, RODERICK LOUIS III
Entity type:Individual
Prefix:MR
First Name:RODERICK
Middle Name:LOUIS
Last Name:MATHESON
Suffix:III
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 1:3305 WEDGEWOOD DR NE APT 201
Mailing Address - Street 2:
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32905-6230
Mailing Address - Country:US
Mailing Address - Phone:321-363-9339
Mailing Address - Fax:
Practice Address - Street 1:2180 JULIAN AVE NE
Practice Address - Street 2:
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32905-4020
Practice Address - Country:US
Practice Address - Phone:321-345-0861
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-15
Last Update Date:2022-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-22-229670106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician