Provider Demographics
NPI:1073670253
Name:RODRIGUEZ, GUSTAVO ALBERT (LISAC)
Entity Type:Individual
Prefix:MR
First Name:GUSTAVO
Middle Name:ALBERT
Last Name:RODRIGUEZ
Suffix:
Gender:M
Credentials:LISAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3802 W 16TH ST
Mailing Address - Street 2:
Mailing Address - City:YUMA
Mailing Address - State:AZ
Mailing Address - Zip Code:85364-4107
Mailing Address - Country:US
Mailing Address - Phone:928-376-0026
Mailing Address - Fax:928-782-2298
Practice Address - Street 1:3802 W 16TH ST
Practice Address - Street 2:
Practice Address - City:YUMA
Practice Address - State:AZ
Practice Address - Zip Code:85364-4107
Practice Address - Country:US
Practice Address - Phone:928-376-0026
Practice Address - Fax:928-782-2298
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLISAC-1257101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ913922Medicare ID - Type UnspecifiedAHCCCS PROVIDER ID