Provider Demographics
NPI:1396131314
Name:RODRIGUEZ-SANTIAGO, IVONNE M (PHD)
Entity type:Individual
Prefix:
First Name:IVONNE
Middle Name:M
Last Name:RODRIGUEZ-SANTIAGO
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 HIGHWAY 466 STE 203P
Mailing Address - Street 2:
Mailing Address - City:LADY LAKE
Mailing Address - State:FL
Mailing Address - Zip Code:32159-6341
Mailing Address - Country:US
Mailing Address - Phone:352-614-0017
Mailing Address - Fax:
Practice Address - Street 1:510 HIGHWAY 466 STE 203P
Practice Address - Street 2:
Practice Address - City:LADY LAKE
Practice Address - State:FL
Practice Address - Zip Code:32159-6341
Practice Address - Country:US
Practice Address - Phone:352-614-0017
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-07
Last Update Date:2021-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10875101YM0800X
MA11123103TC0700X
FLPY10770103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health