Provider Demographics
NPI:1376976308
Name:RODRIGUEZ, EDDIE
Entity Type:Individual
Prefix:
First Name:EDDIE
Middle Name:
Last Name:RODRIGUEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 E SHERIDAN RD
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32901-3122
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4450 W EAU GALLIE BLVD
Practice Address - Street 2:200
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32934-7213
Practice Address - Country:US
Practice Address - Phone:321-726-2860
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-13
Last Update Date:2020-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MH3817101YM0800X
171M00000X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator