Provider Demographics
NPI:1508310921
Name:GONZALEZ RODRIGUEZ, SARA E (PHD)
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:E
Last Name:GONZALEZ RODRIGUEZ
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:345 SMITH AVE N
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55102-2346
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:345 SMITH AVE N
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55102
Practice Address - Country:US
Practice Address - Phone:651-220-6720
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-15
Last Update Date:2019-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE470398819Medicaid