Provider Demographics
NPI:1871300632
Name:RODDEN, JUSTYCE NICOLE
Entity type:Individual
Prefix:
First Name:JUSTYCE
Middle Name:NICOLE
Last Name:RODDEN
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 1:1309 ROSEWOOD CV
Mailing Address - Street 2:
Mailing Address - City:NICEVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32578-4227
Mailing Address - Country:US
Mailing Address - Phone:850-376-6135
Mailing Address - Fax:
Practice Address - Street 1:906 MAR WALT DRIVE
Practice Address - Street 2:SUITE A
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547
Practice Address - Country:US
Practice Address - Phone:651-248-2706
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-16
Last Update Date:2024-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician