Provider Demographics
NPI:1326506908
Name:RODRIGUEZ PEREZ, KRISTINE MARIE
Entity type:Individual
Prefix:
First Name:KRISTINE
Middle Name:MARIE
Last Name:RODRIGUEZ PEREZ
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 1:145 HERON BAY RD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32218-3595
Mailing Address - Country:US
Mailing Address - Phone:352-548-6000
Mailing Address - Fax:
Practice Address - Street 1:145 HERON BAY RD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32218-3595
Practice Address - Country:US
Practice Address - Phone:352-548-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-04
Last Update Date:2024-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA12327101YM0800X
MA11615103T00000X
GAPSY004550103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1134107113OtherMBHP
MA12529OtherHNE
MA1134107113OtherFALLON
MA042622756OtherCCA
MA1134107113OtherNHP
MA1134107113Medicaid
MA1134107113OtherBEACON
MA71756OtherTUFTS
MA997303OtherNETWORK HEALTH
MAY10086OtherMEDICARE