Provider Demographics
NPI:1417494899
Name:RODRIGUEZ, EMMA GRACE (LSW)
Entity Type:Individual
Prefix:
First Name:EMMA
Middle Name:GRACE
Last Name:RODRIGUEZ
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5109 W BROAD ST
Mailing Address - Street 2:SUITE 104
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43228-1648
Mailing Address - Country:US
Mailing Address - Phone:614-279-7690
Mailing Address - Fax:
Practice Address - Street 1:5109 W BROAD ST
Practice Address - Street 2:SUITE 104
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43228
Practice Address - Country:US
Practice Address - Phone:614-279-7690
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-24
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.1700005104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker