Provider Demographics
NPI:1164628111
Name:RODRIGUEZ, IRSA MARIA
Entity Type:Individual
Prefix:
First Name:IRSA
Middle Name:MARIA
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:PO BOX 936
Mailing Address - Street 2:
Mailing Address - City:MANATI
Mailing Address - State:PR
Mailing Address - Zip Code:00674-0936
Mailing Address - Country:US
Mailing Address - Phone:787-854-7056
Mailing Address - Fax:
Practice Address - Street 1:CARR 167 KM 24.3 SECTOR LA CAMBIJA
Practice Address - Street 2:ANTIGUA CENTRAL JUANITA
Practice Address - City:BAYAMON
Practice Address - State:PR
Practice Address - Zip Code:00956
Practice Address - Country:US
Practice Address - Phone:787-854-7056
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR977103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical