Provider Demographics
NPI:1073252193
Name:RODRIGUEZ, LUIS ENRIQUE JR
Entity Type:Individual
Prefix:
First Name:LUIS
Middle Name:ENRIQUE
Last Name:RODRIGUEZ
Suffix:JR
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 1:8660 SW 149TH AVE APT 209
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33193-1442
Mailing Address - Country:US
Mailing Address - Phone:305-632-3836
Mailing Address - Fax:
Practice Address - Street 1:7875 NW 12TH ST STE 110
Practice Address - Street 2:
Practice Address - City:DORAL
Practice Address - State:FL
Practice Address - Zip Code:33126-1815
Practice Address - Country:US
Practice Address - Phone:786-269-3502
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-27
Last Update Date:2022-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-22-215945106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician