Provider Demographics
NPI:1881581353
Name:RODERICK, MARK W
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:W
Last Name:RODERICK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 FORBES RD STE 190
Mailing Address - Street 2:
Mailing Address - City:BRAINTREE
Mailing Address - State:MA
Mailing Address - Zip Code:02184-2622
Mailing Address - Country:US
Mailing Address - Phone:781-300-7503
Mailing Address - Fax:
Practice Address - Street 1:10 FORBES RD STE 190
Practice Address - Street 2:
Practice Address - City:BRAINTREE
Practice Address - State:MA
Practice Address - Zip Code:02184-2622
Practice Address - Country:US
Practice Address - Phone:781-300-7503
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-06-18
Last Update Date:2025-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health