Provider Demographics
NPI:1194018614
Name:RODRIGUEZ, BRIAN (SLP)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:RODRIGUEZ
Suffix:
Gender:M
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2319 W WISCONSIN RD
Mailing Address - Street 2:
Mailing Address - City:EDINBURG
Mailing Address - State:TX
Mailing Address - Zip Code:78539-9604
Mailing Address - Country:US
Mailing Address - Phone:956-490-7278
Mailing Address - Fax:
Practice Address - Street 1:2319 W WISCONSIN RD
Practice Address - Street 2:
Practice Address - City:EDINBURG
Practice Address - State:TX
Practice Address - Zip Code:78539-9604
Practice Address - Country:US
Practice Address - Phone:956-490-7278
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-17
Last Update Date:2011-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX103140235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX03901914OtherTEXAS DRIVERS LICENSE