Provider Demographics
NPI:1154094225
Name:RODRIGUEZ TRINIDAD, EMILLIE
Entity Type:Individual
Prefix:
First Name:EMILLIE
Middle Name:
Last Name:RODRIGUEZ TRINIDAD
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:URB TOA ALTA HEIGHTS AA-16 CALLE 24
Mailing Address - Street 2:
Mailing Address - City:TOA ALTA
Mailing Address - State:PR
Mailing Address - Zip Code:00953
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:706 AVE ESCORIAL
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00920-4731
Practice Address - Country:US
Practice Address - Phone:787-529-1223
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-26
Last Update Date:2021-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR6897103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchoolGroup - Single Specialty