Provider Demographics
NPI:1386878346
Name:RODRIGUEZ, KIMBERLY IVERNE (CRMA)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:IVERNE
Last Name:RODRIGUEZ
Suffix:
Gender:F
Credentials:CRMA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 226
Mailing Address - Street 2:
Mailing Address - City:PATTEN
Mailing Address - State:ME
Mailing Address - Zip Code:04765-0226
Mailing Address - Country:US
Mailing Address - Phone:207-528-2203
Mailing Address - Fax:
Practice Address - Street 1:52 GARDINER STREET
Practice Address - Street 2:
Practice Address - City:PATTEN
Practice Address - State:ME
Practice Address - Zip Code:04765
Practice Address - Country:US
Practice Address - Phone:207-528-2203
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-06
Last Update Date:2009-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME202450000Medicaid