Provider Demographics
NPI:1467496232
Name:RODRIGUEZ FORN, GRICEL (FMD)
Entity Type:Individual
Prefix:
First Name:GRICEL
Middle Name:
Last Name:RODRIGUEZ FORN
Suffix:
Gender:F
Credentials:FMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 347604
Mailing Address - Street 2:
Mailing Address - City:CORAL GABLES
Mailing Address - State:FL
Mailing Address - Zip Code:33234-7604
Mailing Address - Country:US
Mailing Address - Phone:305-984-8422
Mailing Address - Fax:305-857-0070
Practice Address - Street 1:777 E 25TH ST
Practice Address - Street 2:SUITE #102
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33013-3825
Practice Address - Country:US
Practice Address - Phone:305-984-8422
Practice Address - Fax:305-857-0070
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2010-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X, 101Y00000X
FLRN9261633163WP0809X, 163WC0400X, 163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0400XNursing Service ProvidersRegistered NurseCase Management
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult
No163WH0200XNursing Service ProvidersRegistered NurseHome Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL758967100Medicaid