Provider Demographics
NPI:1619399045
Name:RODRIGUEZ, CARLOS (CASAC-T)
Entity Type:Individual
Prefix:
First Name:CARLOS
Middle Name:
Last Name:RODRIGUEZ
Suffix:
Gender:M
Credentials:CASAC-T
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:99 JAMAICA AVE
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:NY
Mailing Address - Zip Code:11763-3503
Mailing Address - Country:US
Mailing Address - Phone:631-543-6200
Mailing Address - Fax:
Practice Address - Street 1:155 INDIAN HEAD RD
Practice Address - Street 2:
Practice Address - City:COMMACK
Practice Address - State:NY
Practice Address - Zip Code:11725-2212
Practice Address - Country:US
Practice Address - Phone:631-543-6200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-21
Last Update Date:2014-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY26042101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY26042OtherOASAS CERTIFICATE