Provider Demographics
NPI:1578180808
Name:RODRIGUEZ, DOUGLAS ALEXIS
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:ALEXIS
Last Name:RODRIGUEZ
Suffix:
Gender:M
Credentials:
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 12623
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94112-0623
Mailing Address - Country:US
Mailing Address - Phone:650-278-5664
Mailing Address - Fax:
Practice Address - Street 1:1720 S AMPHLETT BLVD STE 110
Practice Address - Street 2:
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94402-2710
Practice Address - Country:US
Practice Address - Phone:650-931-3600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-02
Last Update Date:2020-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician