Provider Demographics
NPI:1316807910
Name:RODRIGUEZ, ETHAN ABRAHAM
Entity type:Individual
Prefix:
First Name:ETHAN
Middle Name:ABRAHAM
Last Name:RODRIGUEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5723 MELROSE AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90038-3890
Mailing Address - Country:US
Mailing Address - Phone:323-990-8178
Mailing Address - Fax:
Practice Address - Street 1:5723 MELROSE AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90038-3890
Practice Address - Country:US
Practice Address - Phone:323-990-8178
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-11-15
Last Update Date:2025-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health