Provider Demographics
NPI:1588020812
Name:RODRIGUEZ, ROBERTO (MA)
Entity Type:Individual
Prefix:
First Name:ROBERTO
Middle Name:
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 1:173 CASSEL WAY
Mailing Address - Street 2:
Mailing Address - City:BASTROP
Mailing Address - State:TX
Mailing Address - Zip Code:78602-5727
Mailing Address - Country:US
Mailing Address - Phone:651-402-9564
Mailing Address - Fax:
Practice Address - Street 1:1604 INDUSTRY DR STE 105
Practice Address - Street 2:
Practice Address - City:BASTROP
Practice Address - State:TX
Practice Address - Zip Code:78602-4622
Practice Address - Country:US
Practice Address - Phone:737-251-2707
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-31
Last Update Date:2022-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN302348101YA0400X
MN3074106H00000X
TX204734106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)