Provider Demographics
NPI:1699862508
Name:RODDEN, MICHAEL THOMAS (PT)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:THOMAS
Last Name:RODDEN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:542 W SWEET CLOVER RD
Mailing Address - Street 2:
Mailing Address - City:ROUND LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60073
Mailing Address - Country:US
Mailing Address - Phone:847-546-4293
Mailing Address - Fax:
Practice Address - Street 1:50 S MILWAUKEE AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:LAKE VILLA
Practice Address - State:IL
Practice Address - Zip Code:60046
Practice Address - Country:US
Practice Address - Phone:847-265-3491
Practice Address - Fax:847-265-3498
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist