Provider Demographics
NPI:1285716936
Name:RODRIGUEZ, MARY JO (PT)
Entity type:Individual
Prefix:
First Name:MARY JO
Middle Name:
Last Name:RODRIGUEZ
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:J
Other - Last Name:SOINE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:141A MESCALERO TRAIL
Mailing Address - Street 2:
Mailing Address - City:RUIDOSO
Mailing Address - State:NM
Mailing Address - Zip Code:88345
Mailing Address - Country:US
Mailing Address - Phone:575-257-4753
Mailing Address - Fax:575-257-4753
Practice Address - Street 1:141A MESCALERO TRAIL
Practice Address - Street 2:
Practice Address - City:RUIDOSO
Practice Address - State:NM
Practice Address - Zip Code:88345
Practice Address - Country:US
Practice Address - Phone:575-257-4753
Practice Address - Fax:575-257-4753
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-20
Last Update Date:2009-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1528225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMB9609Medicaid
NMB9609Medicaid