Provider Demographics
NPI:1588369359
Name:ACOSTA RODRIGUEZ, RAFAEL
Entity type:Individual
Prefix:
First Name:RAFAEL
Middle Name:
Last Name:ACOSTA RODRIGUEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6538 W 2ND CT
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33012-6740
Mailing Address - Country:US
Mailing Address - Phone:786-830-2653
Mailing Address - Fax:
Practice Address - Street 1:12150 SW 128TH CT STE 220
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33186-4674
Practice Address - Country:US
Practice Address - Phone:786-830-2653
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-03
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-23-117465106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty