Provider Demographics
NPI:1962217489
Name:RODDENBERRY, DAVID EDWIN
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:EDWIN
Last Name:RODDENBERRY
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 SEAHILL DR
Mailing Address - Street 2:
Mailing Address - City:SAINT AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32092-1112
Mailing Address - Country:US
Mailing Address - Phone:407-748-0982
Mailing Address - Fax:
Practice Address - Street 1:109 NATURE WALK PKWY UNIT 104
Practice Address - Street 2:
Practice Address - City:SAINT AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32092-5065
Practice Address - Country:US
Practice Address - Phone:407-748-0982
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-11
Last Update Date:2025-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH25268101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health