Provider Demographics
NPI:1376301754
Name:RODRIGUEZ, OLIVIA GRACE
Entity Type:Individual
Prefix:
First Name:OLIVIA
Middle Name:GRACE
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 1:409 ORANGE CT
Mailing Address - Street 2:
Mailing Address - City:HAINES CITY
Mailing Address - State:FL
Mailing Address - Zip Code:33844-8541
Mailing Address - Country:US
Mailing Address - Phone:863-280-4485
Mailing Address - Fax:
Practice Address - Street 1:102 PARK PLACE BLVD STE C1
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-2358
Practice Address - Country:US
Practice Address - Phone:407-385-0728
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-11
Last Update Date:2024-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician