Provider Demographics
NPI:1538308036
Name:RODRIGUEZ, EZEQUIEL MEDINA (MA)
Entity Type:Individual
Prefix:
First Name:EZEQUIEL
Middle Name:MEDINA
Last Name:RODRIGUEZ
Suffix:
Gender:M
Credentials:MA
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 141446
Mailing Address - Street 2:
Mailing Address - City:ARECIBO
Mailing Address - State:PR
Mailing Address - Zip Code:00614-1446
Mailing Address - Country:US
Mailing Address - Phone:787-633-3335
Mailing Address - Fax:
Practice Address - Street 1:COND SANTA RITA # 1000
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00925-2857
Practice Address - Country:US
Practice Address - Phone:787-633-3335
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-07
Last Update Date:2009-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103TB0200X, 103TC2200X, 103TF0000X, 103TM1800X
PR3270103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
No103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities