Provider Demographics
NPI:1568209179
Name:RODRIGUEZ, LYNETTE SAMANTHA
Entity type:Individual
Prefix:
First Name:LYNETTE
Middle Name:SAMANTHA
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 1:717 ERIE ST
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91768-2146
Mailing Address - Country:US
Mailing Address - Phone:626-625-4982
Mailing Address - Fax:
Practice Address - Street 1:717 ERIE ST
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91768-2146
Practice Address - Country:US
Practice Address - Phone:626-625-4982
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-10
Last Update Date:2024-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician