Provider Demographics
NPI:1417412016
Name:RODRIGUEZ, IRENE ASHLEY
Entity Type:Individual
Prefix:
First Name:IRENE
Middle Name:ASHLEY
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 1:5900 SHARON WOODS BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43229-2600
Mailing Address - Country:US
Mailing Address - Phone:148-956-8186
Mailing Address - Fax:
Practice Address - Street 1:5900 SHARON WOODS BLVD STE A
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43229-2600
Practice Address - Country:US
Practice Address - Phone:148-956-8186
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-07
Last Update Date:2020-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH171M00000X
251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH171MOOOOOXMedicaid