Provider Demographics
NPI:1992423693
Name:DECLET RODRIGUEZ, GUADALUPE
Entity type:Individual
Prefix:
First Name:GUADALUPE
Middle Name:
Last Name:DECLET RODRIGUEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LUPITA
Other - Middle Name:
Other - Last Name:RODRIGUEZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1903 HUMANKIND WAY
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24503-6313
Mailing Address - Country:US
Mailing Address - Phone:434-846-1124
Mailing Address - Fax:434-846-1052
Practice Address - Street 1:1903 HUMANKIND WAY
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24503-6313
Practice Address - Country:US
Practice Address - Phone:434-846-1124
Practice Address - Fax:434-846-1052
Is Sole Proprietor?:No
Enumeration Date:2022-08-18
Last Update Date:2022-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701011710101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAA60426548OtherDRIVER'S LICENSE