Provider Demographics
NPI:1962099499
Name:RODRIGUEZ, MARIA TERESA (R1379850320)
Entity type:Individual
Prefix:
First Name:MARIA
Middle Name:TERESA
Last Name:RODRIGUEZ
Suffix:
Gender:F
Credentials:R1379850320
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 180461
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90018-9729
Mailing Address - Country:US
Mailing Address - Phone:323-350-0417
Mailing Address - Fax:
Practice Address - Street 1:2504 W MANCHESTER BLVD
Practice Address - Street 2:
Practice Address - City:INGLEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90305-2520
Practice Address - Country:US
Practice Address - Phone:323-751-3805
Practice Address - Fax:323-750-5885
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-30
Last Update Date:2020-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1379850320101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)