Provider Demographics
NPI:1104433051
Name:RODRIGUEZ, TIMOTHY DAVID (RBT)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:DAVID
Last Name:RODRIGUEZ
Suffix:
Gender:M
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:86156 OAK TREE LN
Mailing Address - Street 2:
Mailing Address - City:YULEE
Mailing Address - State:FL
Mailing Address - Zip Code:32097-5584
Mailing Address - Country:US
Mailing Address - Phone:904-826-6911
Mailing Address - Fax:
Practice Address - Street 1:87009 PROFESSIONAL WAY
Practice Address - Street 2:
Practice Address - City:YULEE
Practice Address - State:FL
Practice Address - Zip Code:32097-3400
Practice Address - Country:US
Practice Address - Phone:904-849-7179
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-24
Last Update Date:2020-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL20-136762106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician