Provider Demographics
NPI:1699127084
Name:RODRIGUEZ-VEGA, LOURDES (BCBA)
Entity type:Individual
Prefix:
First Name:LOURDES
Middle Name:
Last Name:RODRIGUEZ-VEGA
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1317 EDGEWATER DR STE 2560
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32804-6350
Mailing Address - Country:US
Mailing Address - Phone:212-210-9741
Mailing Address - Fax:321-256-5545
Practice Address - Street 1:1317 EDGEWATER DR STE 2560
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32804-6350
Practice Address - Country:US
Practice Address - Phone:321-210-9741
Practice Address - Fax:321-256-5545
Is Sole Proprietor?:No
Enumeration Date:2016-07-08
Last Update Date:2021-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1-17-26673103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1255377099Medicaid