Provider Demographics
NPI:1467807586
Name:RODRIGUEZ, RUDIANN
Entity Type:Individual
Prefix:
First Name:RUDIANN
Middle Name:
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 1:34 COUNTRY CLUB DR APT E
Mailing Address - Street 2:
Mailing Address - City:CORAM
Mailing Address - State:NY
Mailing Address - Zip Code:11727-3425
Mailing Address - Country:US
Mailing Address - Phone:631-243-1765
Mailing Address - Fax:631-243-3716
Practice Address - Street 1:1014 GRAND BLVD STE 5
Practice Address - Street 2:
Practice Address - City:DEER PARK
Practice Address - State:NY
Practice Address - Zip Code:11729-5782
Practice Address - Country:US
Practice Address - Phone:631-243-1765
Practice Address - Fax:631-243-3716
Is Sole Proprietor?:No
Enumeration Date:2016-04-26
Last Update Date:2016-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist