Provider Demographics
NPI:1063212959
Name:RODRIGUEZ, KANISHA MARIE (LSW)
Entity type:Individual
Prefix:
First Name:KANISHA
Middle Name:MARIE
Last Name:RODRIGUEZ
Suffix:
Gender:
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2017 WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:BLUE ISLAND
Mailing Address - State:IL
Mailing Address - Zip Code:60406-2226
Mailing Address - Country:US
Mailing Address - Phone:708-752-2524
Mailing Address - Fax:
Practice Address - Street 1:3020 WOODCREEK DR STE A2
Practice Address - Street 2:
Practice Address - City:DOWNERS GROVE
Practice Address - State:IL
Practice Address - Zip Code:60515-5416
Practice Address - Country:US
Practice Address - Phone:630-797-9807
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-18
Last Update Date:2025-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150.111678104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker