Provider Demographics
NPI:1003406810
Name:RODRIGUEZ TRUJILLO, KENNY JUNIOR
Entity Type:Individual
Prefix:
First Name:KENNY
Middle Name:JUNIOR
Last Name:RODRIGUEZ TRUJILLO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 BON AIR ROAD, UNIT B - 1ST FLOOR (ACCESS TEAM)
Mailing Address - Street 2:
Mailing Address - City:GREENBRAE
Mailing Address - State:CA
Mailing Address - Zip Code:94904
Mailing Address - Country:US
Mailing Address - Phone:888-818-1115
Mailing Address - Fax:
Practice Address - Street 1:250 BON AIR ROAD, UNIT B - 1ST FLOOR (ACCESS TEAM)
Practice Address - Street 2:
Practice Address - City:GREENBRAE
Practice Address - State:CA
Practice Address - Zip Code:94904
Practice Address - Country:US
Practice Address - Phone:888-818-1115
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-25
Last Update Date:2024-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMPSS-IJQGWM106S00000X, 225400000X, 175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner