Provider Demographics
NPI:1306577432
Name:RODRIGUEZ, DIANA MARISOL
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:MARISOL
Last Name:RODRIGUEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:DIANA
Other - Middle Name:MARISOL
Other - Last Name:MCGILTON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:188 PARKER RD
Mailing Address - Street 2:
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30252-2746
Mailing Address - Country:US
Mailing Address - Phone:678-326-8175
Mailing Address - Fax:
Practice Address - Street 1:260 PEACHTREE ST NW STE 2200
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30303-1292
Practice Address - Country:US
Practice Address - Phone:877-418-2186
Practice Address - Fax:866-500-2186
Is Sole Proprietor?:No
Enumeration Date:2022-06-20
Last Update Date:2022-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician