Provider Demographics
NPI:1295833770
Name:RODRIGUEZ, GUILLERMO (LCDC)
Entity Type:Individual
Prefix:MR
First Name:GUILLERMO
Middle Name:
Last Name:RODRIGUEZ
Suffix:
Gender:M
Credentials:LCDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1747 CITADEL PLZ STE 205
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78209-1017
Mailing Address - Country:US
Mailing Address - Phone:210-788-2762
Mailing Address - Fax:
Practice Address - Street 1:1747 CITADEL PLZ STE 205
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78209-1017
Practice Address - Country:US
Practice Address - Phone:210-788-2762
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX11022101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ097782OtherAHCCCS
TX11758628OtherCAQH
AZ7739933OtherAETNA
TX11758628OtherCAQH