Provider Demographics
NPI:1558619205
Name:RODRIGUEZ, MICHAEL A (MSW)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:A
Last Name:RODRIGUEZ
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:89-23 210TH ST.
Mailing Address - Street 2:
Mailing Address - City:QUEENS VILLAGE
Mailing Address - State:NY
Mailing Address - Zip Code:11427-2226
Mailing Address - Country:US
Mailing Address - Phone:917-687-5623
Mailing Address - Fax:
Practice Address - Street 1:31-36 88TH STREET
Practice Address - Street 2:JACKSON DEVELOPMENTAL CENTER
Practice Address - City:JACKSON HEIGHTS
Practice Address - State:NY
Practice Address - Zip Code:11369
Practice Address - Country:US
Practice Address - Phone:718-205-1919
Practice Address - Fax:718-205-0178
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-28
Last Update Date:2012-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY6513911221041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool