Provider Demographics
NPI:1114088291
Name:RODRIGUES, MARY TERESA (LPCC/LADAC)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:TERESA
Last Name:RODRIGUES
Suffix:
Gender:
Credentials:LPCC/LADAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4730 BECKNER RD
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87507-3691
Mailing Address - Country:US
Mailing Address - Phone:059-894-5005
Mailing Address - Fax:054-438-3135
Practice Address - Street 1:4730 BECKNER RD
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87507-3691
Practice Address - Country:US
Practice Address - Phone:505-989-4500
Practice Address - Fax:505-443-8313
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-13
Last Update Date:2025-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCAD0163871101YA0400X
NM0120871101YM0800X
MT1106 LCPC101YP2500X
NMCCMH0120871101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0000743550OtherBLUE CROSS-SHIELD OF MONT