Provider Demographics
NPI:1386961340
Name:RODRIGUEZ, RAUL (LCSW)
Entity type:Individual
Prefix:
First Name:RAUL
Middle Name:
Last Name:RODRIGUEZ
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2231 FAULKNER NERD
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30324-4224
Mailing Address - Country:US
Mailing Address - Phone:404-229-9539
Mailing Address - Fax:
Practice Address - Street 1:1586 ATKINSON RD
Practice Address - Street 2:SUITE 103
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30043-5972
Practice Address - Country:US
Practice Address - Phone:404-299-9539
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-29
Last Update Date:2015-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
GACSW003234101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)