Provider Demographics
NPI:1356081582
Name:RODRIGUEZ, DOMINIQUE LIANA ANGELINE
Entity Type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:LIANA ANGELINE
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 1:768 DELAWARE AVE
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14209-2006
Mailing Address - Country:US
Mailing Address - Phone:716-566-1288
Mailing Address - Fax:833-790-5378
Practice Address - Street 1:227 THORN AVE
Practice Address - Street 2:
Practice Address - City:ORCHARD PARK
Practice Address - State:NY
Practice Address - Zip Code:14127-2600
Practice Address - Country:US
Practice Address - Phone:716-662-2040
Practice Address - Fax:716-662-0019
Is Sole Proprietor?:No
Enumeration Date:2022-03-29
Last Update Date:2022-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY114584104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker