Provider Demographics
NPI:1578038196
Name:RODRIGUES, KIRSTIN MARIE
Entity Type:Individual
Prefix:
First Name:KIRSTIN
Middle Name:MARIE
Last Name:RODRIGUES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KIRSTIN
Other - Middle Name:MARIE
Other - Last Name:VOSE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1981 EAST AVE
Mailing Address - Street 2:
Mailing Address - City:HAYWARD
Mailing Address - State:CA
Mailing Address - Zip Code:94541-5405
Mailing Address - Country:US
Mailing Address - Phone:510-673-4179
Mailing Address - Fax:
Practice Address - Street 1:39210 STATE ST STE 220
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94538-1456
Practice Address - Country:US
Practice Address - Phone:510-894-4135
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-10
Last Update Date:2018-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
CA46-1305562106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician