Provider Demographics
NPI:1851800239
Name:RODRIGUEZ, IVY (MSED)
Entity type:Individual
Prefix:
First Name:IVY
Middle Name:
Last Name:RODRIGUEZ
Suffix:
Gender:F
Credentials:MSED
Other - Prefix:MS
Other - First Name:IVY
Other - Middle Name:
Other - Last Name:DELEON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MSED
Mailing Address - Street 1:253 W 35TH ST FL 16
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10001-1907
Mailing Address - Country:US
Mailing Address - Phone:718-728-8476
Mailing Address - Fax:
Practice Address - Street 1:24537 60TH AVE
Practice Address - Street 2:
Practice Address - City:LITTLE NECK
Practice Address - State:NY
Practice Address - Zip Code:11362-2014
Practice Address - Country:US
Practice Address - Phone:718-728-8476
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-28
Last Update Date:2017-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist