Provider Demographics
NPI:1629412580
Name:RODRIGUEZ, AMANDA MARIA (CSAC, CSIT)
Entity Type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:MARIA
Last Name:RODRIGUEZ
Suffix:
Gender:F
Credentials:CSAC, CSIT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5735 DURAND AVE
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:WI
Mailing Address - Zip Code:53406-5011
Mailing Address - Country:US
Mailing Address - Phone:262-598-1392
Mailing Address - Fax:262-598-1395
Practice Address - Street 1:5735 DURAND AVE
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:WI
Practice Address - Zip Code:53406-5011
Practice Address - Country:US
Practice Address - Phone:262-598-1392
Practice Address - Fax:262-598-1395
Is Sole Proprietor?:No
Enumeration Date:2013-04-23
Last Update Date:2017-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15693-133101YA0400X
WI16021-132101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100037952Medicaid