Provider Demographics
NPI:1679357974
Name:RODRIGUEZ, KAYLA MARIE
Entity Type:Individual
Prefix:MRS
First Name:KAYLA
Middle Name:MARIE
Last Name:RODRIGUEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:365 LINCOLN WAY NE
Mailing Address - Street 2:
Mailing Address - City:LUDOWICI
Mailing Address - State:GA
Mailing Address - Zip Code:31316-5676
Mailing Address - Country:US
Mailing Address - Phone:919-478-3601
Mailing Address - Fax:
Practice Address - Street 1:600 E OGLETHORPE HWY
Practice Address - Street 2:
Practice Address - City:HINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:31313-2806
Practice Address - Country:US
Practice Address - Phone:912-667-8730
Practice Address - Fax:973-888-1377
Is Sole Proprietor?:No
Enumeration Date:2023-08-21
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARBT-23-287693106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician