Basic Information
| Provider Information | |||||||||
| NPI: | 1861750994 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WINSTON | ||||||||
| FirstName: | RODERICK | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1413 FALL BRANCH DR | ||||||||
| Address2: | |||||||||
| City: | PHENIX CITY | ||||||||
| State: | AL | ||||||||
| PostalCode: | 368671573 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7062491017 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2100 COMER AVE | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 319048725 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7063230174 | ||||||||
| FaxNumber: | 7062563264 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/26/2012 | ||||||||
| LastUpdateDate: | 04/26/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.