Provider Demographics
NPI:1962163147
Name:RODRIGUEZ, ANGELICA MARIE
Entity type:Individual
Prefix:
First Name:ANGELICA
Middle Name:MARIE
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 1:129 MUSH BLUFF TRL
Mailing Address - Street 2:
Mailing Address - City:SAINT MARYS
Mailing Address - State:GA
Mailing Address - Zip Code:31558-3337
Mailing Address - Country:US
Mailing Address - Phone:203-833-4131
Mailing Address - Fax:
Practice Address - Street 1:87009 PROFESSIONAL WAY
Practice Address - Street 2:
Practice Address - City:YULEE
Practice Address - State:FL
Practice Address - Zip Code:32097-3400
Practice Address - Country:US
Practice Address - Phone:904-544-5276
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-10
Last Update Date:2022-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician