Provider Demographics
NPI:1194140657
Name:RODRIGUEZ GONZALEZ, MAGDA ELLEN (PSYD)
Entity type:Individual
Prefix:MRS
First Name:MAGDA
Middle Name:ELLEN
Last Name:RODRIGUEZ GONZALEZ
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:MRS
Other - First Name:MAGDA
Other - Middle Name:ELLEN
Other - Last Name:GONZALEZ NIEVES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA
Mailing Address - Street 1:1602 WILD MUSTARD DRIVE
Mailing Address - Street 2:
Mailing Address - City:ODENTON
Mailing Address - State:MD
Mailing Address - Zip Code:21113-6041
Mailing Address - Country:US
Mailing Address - Phone:301-593-4040
Mailing Address - Fax:301-593-9148
Practice Address - Street 1:13 ANNAPOLIS ROAD
Practice Address - Street 2:SUITE 207
Practice Address - City:ODENTON
Practice Address - State:MD
Practice Address - Zip Code:21113-1216
Practice Address - Country:US
Practice Address - Phone:410-216-4992
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-20
Last Update Date:2021-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD05341103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical