Provider Demographics
NPI:1477806685
Name:RODRIGUEZ, KELLY D
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:D
Last Name:RODRIGUEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:DALE
Other - Last Name:RUTLEDGE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4705 CAREO DR
Mailing Address - Street 2:
Mailing Address - City:ANTELOPE
Mailing Address - State:CA
Mailing Address - Zip Code:95843-5182
Mailing Address - Country:US
Mailing Address - Phone:916-276-2001
Mailing Address - Fax:
Practice Address - Street 1:4705 CAREO DR
Practice Address - Street 2:
Practice Address - City:ANTELOPE
Practice Address - State:CA
Practice Address - Zip Code:95843-5182
Practice Address - Country:US
Practice Address - Phone:916-276-2001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-25
Last Update Date:2012-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health