Provider Demographics
NPI:1609110998
Name:RODRIGUEZ, MARY-KATHRYN (IMFT)
Entity Type:Individual
Prefix:
First Name:MARY-KATHRYN
Middle Name:
Last Name:RODRIGUEZ
Suffix:
Gender:F
Credentials:IMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1451 S CENTRAL DR
Mailing Address - Street 2:
Mailing Address - City:BEAVERCREEK
Mailing Address - State:OH
Mailing Address - Zip Code:45432-2905
Mailing Address - Country:US
Mailing Address - Phone:801-652-0406
Mailing Address - Fax:
Practice Address - Street 1:4930 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:OH
Practice Address - Zip Code:45044-5425
Practice Address - Country:US
Practice Address - Phone:801-652-0406
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-27
Last Update Date:2015-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1500006106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist