Provider Demographics
NPI:1043045651
Name:ROEDIGER, KYRA DAWN
Entity type:Individual
Prefix:
First Name:KYRA
Middle Name:DAWN
Last Name:ROEDIGER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 MARKHAM ST
Mailing Address - Street 2:
Mailing Address - City:FORT LIBERTY
Mailing Address - State:NC
Mailing Address - Zip Code:28307-3406
Mailing Address - Country:US
Mailing Address - Phone:541-324-4196
Mailing Address - Fax:
Practice Address - Street 1:89 LAKEWIND CT
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:NC
Practice Address - Zip Code:27332-0612
Practice Address - Country:US
Practice Address - Phone:919-601-4685
Practice Address - Fax:910-356-9466
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-04
Last Update Date:2024-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty