Provider Demographics
NPI:1982115408
Name:CHAVEZ RODRIGUEZ, CARLOS RAYMUNDO (NON-COUNSELOR)
Entity type:Individual
Prefix:
First Name:CARLOS RAYMUNDO
Middle Name:
Last Name:CHAVEZ RODRIGUEZ
Suffix:
Gender:M
Credentials:NON-COUNSELOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1412 SWEET HOME RD
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14228-2795
Mailing Address - Country:US
Mailing Address - Phone:716-589-1411
Mailing Address - Fax:716-276-3051
Practice Address - Street 1:1412 SWEET HOME RD. SUITE 3-5
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14228
Practice Address - Country:US
Practice Address - Phone:716-884-0700
Practice Address - Fax:716-884-0631
Is Sole Proprietor?:No
Enumeration Date:2017-10-24
Last Update Date:2021-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NYP13798101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program