Provider Demographics
NPI:1154744274
Name:RODRIGUEZ, SHANTAL JOANNAH
Entity type:Individual
Prefix:
First Name:SHANTAL
Middle Name:JOANNAH
Last Name:RODRIGUEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4000 W METROPOLITAN DR STE 401
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92868-3506
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4000 W METROPOLITAN DR STE 401
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-3506
Practice Address - Country:US
Practice Address - Phone:714-834-5151
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-24
Last Update Date:2024-03-20
Deactivation Date:2024-03-09
Deactivation Code:
Reactivation Date:2024-03-18
Provider Licenses
StateLicense IDTaxonomies
CA119824104100000X
172V00000X, 225400000X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No172V00000XOther Service ProvidersCommunity Health Worker
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner