Provider Demographics
NPI:1114280955
Name:RODRIGUEZ, DIANDRA
Entity Type:Individual
Prefix:MISS
First Name:DIANDRA
Middle Name:
Last Name:RODRIGUEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:147-24 79TH AVENUE
Mailing Address - Street 2:APT 3N
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11367-1026
Mailing Address - Country:US
Mailing Address - Phone:347-709-1180
Mailing Address - Fax:
Practice Address - Street 1:147-24 79TH AVENUE
Practice Address - Street 2:APT 3N
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11367-1026
Practice Address - Country:US
Practice Address - Phone:347-709-1180
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-18
Last Update Date:2016-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007528101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health