Provider Demographics
NPI:1114792348
Name:RODRIGUEZ, SHADE CHANTEL (CIT)
Entity Type:Individual
Prefix:
First Name:SHADE
Middle Name:CHANTEL
Last Name:RODRIGUEZ
Suffix:
Gender:F
Credentials:CIT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2321 US-80
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71203
Mailing Address - Country:US
Mailing Address - Phone:318-600-3333
Mailing Address - Fax:
Practice Address - Street 1:5542 WHITES FERRY RD LOT 4
Practice Address - Street 2:
Practice Address - City:WEST MONROE
Practice Address - State:LA
Practice Address - Zip Code:71291-8839
Practice Address - Country:US
Practice Address - Phone:318-614-7826
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-17
Last Update Date:2023-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA5718101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)