Provider Demographics
NPI:1336702836
Name:RODRIGUEZ, LYDIA (CMT)
Entity Type:Individual
Prefix:
First Name:LYDIA
Middle Name:
Last Name:RODRIGUEZ
Suffix:
Gender:F
Credentials:CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4162 ESTRELLA AVE APT 4
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92105-2055
Mailing Address - Country:US
Mailing Address - Phone:347-503-8835
Mailing Address - Fax:
Practice Address - Street 1:1149 N 2ND ST
Practice Address - Street 2:
Practice Address - City:EL CAJON
Practice Address - State:CA
Practice Address - Zip Code:92021-5024
Practice Address - Country:US
Practice Address - Phone:619-440-2440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-19
Last Update Date:2019-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA76755225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist