Provider Demographics
NPI:1366757445
Name:RODRIGUEZ, MYRIEL
Entity type:Individual
Prefix:
First Name:MYRIEL
Middle Name:
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 1:428 COLUMBUS AVE
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06519-1233
Mailing Address - Country:US
Mailing Address - Phone:203-503-3055
Mailing Address - Fax:203-503-3066
Practice Address - Street 1:428 COLUMBUS AVE
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06519-1233
Practice Address - Country:US
Practice Address - Phone:203-503-3055
Practice Address - Fax:203-503-3066
Is Sole Proprietor?:No
Enumeration Date:2010-08-12
Last Update Date:2013-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT3284103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004235918Medicaid