Provider Demographics
NPI:1033418165
Name:RODRIGUEZ, ALYSE COSIMA (LMT)
Entity Type:Individual
Prefix:
First Name:ALYSE
Middle Name:COSIMA
Last Name:RODRIGUEZ
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8450 GATE PKWY W # 16254
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-1049
Mailing Address - Country:US
Mailing Address - Phone:904-352-5292
Mailing Address - Fax:
Practice Address - Street 1:3576 SAINT JOHNS AVE
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32205-8446
Practice Address - Country:US
Practice Address - Phone:904-387-9355
Practice Address - Fax:904-387-6701
Is Sole Proprietor?:No
Enumeration Date:2011-03-15
Last Update Date:2011-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA 59574225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist