Provider Demographics
NPI:1215978820
Name:RODERICK, DIANA JANE (LPC)
Entity type:Individual
Prefix:MRS
First Name:DIANA
Middle Name:JANE
Last Name:RODERICK
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 12019
Mailing Address - Street 2:
Mailing Address - City:COLLEGE STATION
Mailing Address - State:TX
Mailing Address - Zip Code:77842-2019
Mailing Address - Country:US
Mailing Address - Phone:979-764-8127
Mailing Address - Fax:
Practice Address - Street 1:1701 SOUTHWEST PKWY
Practice Address - Street 2:SUITE 201
Practice Address - City:COLLEGE STATION
Practice Address - State:TX
Practice Address - Zip Code:77840-6911
Practice Address - Country:US
Practice Address - Phone:979-764-8127
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX16128101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor