Provider Demographics
NPI:1164925962
Name:RODRIGUEZ, GRETTA MARIE
Entity Type:Individual
Prefix:
First Name:GRETTA
Middle Name:MARIE
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 1:4100 W 11TH LN
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33012-4163
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4100 W 11TH LN
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33012-4163
Practice Address - Country:US
Practice Address - Phone:786-609-8324
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-18
Last Update Date:2018-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician