Provider Demographics
NPI:1639620388
Name:RODRIGUEZ, MAXINE LOUISE (MS CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:MAXINE
Middle Name:LOUISE
Last Name:RODRIGUEZ
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:MS
Other - First Name:MAXINE
Other - Middle Name:LOUISE
Other - Last Name:GONZALES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS CCC-SLP
Mailing Address - Street 1:3939 BERNARD ST
Mailing Address - Street 2:STE 6
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93306-3168
Mailing Address - Country:US
Mailing Address - Phone:661-230-6230
Mailing Address - Fax:661-348-4390
Practice Address - Street 1:3939 BERNARD ST
Practice Address - Street 2:STE 6
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93306-3168
Practice Address - Country:US
Practice Address - Phone:661-230-6230
Practice Address - Fax:661-348-4390
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-18
Last Update Date:2017-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA21955235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1740635853Medicaid
CA1740635853Medicare NSC
CA1740635853Medicare Oscar/Certification
CA1740635853Medicare PIN
CA1740635853Medicare UPIN