Provider Demographics
NPI:1609917897
Name:RODRIGUEZ, MARILYN (MS)
Entity Type:Individual
Prefix:MRS
First Name:MARILYN
Middle Name:
Last Name:RODRIGUEZ
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:HC 645 BOX 6387
Mailing Address - Street 2:
Mailing Address - City:TRUJILLO ALTO
Mailing Address - State:PR
Mailing Address - Zip Code:00976-9746
Mailing Address - Country:US
Mailing Address - Phone:787-292-0205
Mailing Address - Fax:787-292-0205
Practice Address - Street 1:200 AVE CUPEY GDNS
Practice Address - Street 2:PLAZA CUPEY GARDEN, SECTOR #3
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00926-7341
Practice Address - Country:US
Practice Address - Phone:787-292-0205
Practice Address - Fax:787-292-0205
Is Sole Proprietor?:No
Enumeration Date:2007-02-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR1693103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR1713OtherPSYCHOLOGIST
PR2403OtherPSYCHOLOGIST
PR2403OtherPSYCHOLOGIST