Provider Demographics
NPI:1194957050
Name:RODRIGUEZ, MARTHA A
Entity type:Individual
Prefix:MRS
First Name:MARTHA
Middle Name:A
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 1:4501 S WASHTENAW AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60632-1942
Mailing Address - Country:US
Mailing Address - Phone:773-376-1650
Mailing Address - Fax:
Practice Address - Street 1:4501 S WASHTENAW AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60632-1942
Practice Address - Country:US
Practice Address - Phone:773-376-1650
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-11
Last Update Date:2012-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0123101041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical