Provider Demographics
NPI:1114088291
Name:RODRIGUES, MARY TERESA (LCPC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:TERESA
Last Name:RODRIGUES
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 319
Mailing Address - Street 2:
Mailing Address - City:TESUQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87574-0319
Mailing Address - Country:US
Mailing Address - Phone:505-490-1801
Mailing Address - Fax:505-455-8876
Practice Address - Street 1:505 CAMINO DE LOS MARQUEZ
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-1837
Practice Address - Country:US
Practice Address - Phone:505-490-1801
Practice Address - Fax:505-455-8876
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-13
Last Update Date:2016-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT1106 LCPC101YP2500X
NM0120871101YM0800X
NM0163871101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0000743550OtherBLUE CROSS-SHIELD OF MONT