Provider Demographics
NPI:1619055126
Name:RODRIGUEZ, IDALIS (MSW)
Entity Type:Individual
Prefix:
First Name:IDALIS
Middle Name:
Last Name:RODRIGUEZ
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1204 AVE MIRAMAR
Mailing Address - Street 2:
Mailing Address - City:ARECIBO
Mailing Address - State:PR
Mailing Address - Zip Code:00612-2763
Mailing Address - Country:US
Mailing Address - Phone:787-816-3929
Mailing Address - Fax:
Practice Address - Street 1:1204 AVE MIRAMAR
Practice Address - Street 2:
Practice Address - City:ARECIBO
Practice Address - State:PR
Practice Address - Zip Code:00612-2763
Practice Address - Country:US
Practice Address - Phone:787-816-3929
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR63171041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical