Provider Demographics
NPI:1487160982
Name:RODRIGUEZ, SARA LUCIA
Entity type:Individual
Prefix:
First Name:SARA
Middle Name:LUCIA
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 1:12524 SW 126TH AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33186-9037
Mailing Address - Country:US
Mailing Address - Phone:305-924-4663
Mailing Address - Fax:
Practice Address - Street 1:12524 SW 126TH AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33186-9037
Practice Address - Country:US
Practice Address - Phone:059-244-6633
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-19
Last Update Date:2024-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
FL222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
No106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL020899400Medicaid