Provider Demographics
NPI:1275817025
Name:RODRIGUEZ, SAMUEL JR (BA)
Entity Type:Individual
Prefix:MR
First Name:SAMUEL
Middle Name:
Last Name:RODRIGUEZ
Suffix:JR
Gender:M
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11813 WOLCOTT ST
Mailing Address - Street 2:
Mailing Address - City:ADELANTO
Mailing Address - State:CA
Mailing Address - Zip Code:92301-3737
Mailing Address - Country:US
Mailing Address - Phone:909-725-8508
Mailing Address - Fax:
Practice Address - Street 1:1460 E HOLT AVE
Practice Address - Street 2:#8
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91767-5856
Practice Address - Country:US
Practice Address - Phone:909-865-0209
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-28
Last Update Date:2011-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health