Provider Demographics
NPI:1063491991
Name:RODRIGUEZ, MICHAEL DAMIEN (MSW)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:DAMIEN
Last Name:RODRIGUEZ
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1872 MONTREAL RD
Mailing Address - Street 2:
Mailing Address - City:TUCKER
Mailing Address - State:GA
Mailing Address - Zip Code:30084-5709
Mailing Address - Country:US
Mailing Address - Phone:770-496-9400
Mailing Address - Fax:770-496-9495
Practice Address - Street 1:1700 HOSPITAL SOUTH DR
Practice Address - Street 2:SUITE 102
Practice Address - City:AUSTELL
Practice Address - State:GA
Practice Address - Zip Code:30106-6810
Practice Address - Country:US
Practice Address - Phone:770-948-3233
Practice Address - Fax:770-944-1537
Is Sole Proprietor?:No
Enumeration Date:2006-01-10
Last Update Date:2010-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA00308041041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAQ00909Medicare UPIN
GA80BBFRFMedicare ID - Type Unspecified