Provider Demographics
NPI:1679936876
Name:RODRIGUEZ, JUAN GERARDO (LCDO)
Entity Type:Individual
Prefix:
First Name:JUAN
Middle Name:GERARDO
Last Name:RODRIGUEZ
Suffix:
Gender:M
Credentials:LCDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:#68 CALLE STA. CRUZ TORRE SAN PABLO SUITE 702
Mailing Address - Street 2:
Mailing Address - City:BAYAMON
Mailing Address - State:PR
Mailing Address - Zip Code:00961-7037
Mailing Address - Country:US
Mailing Address - Phone:787-428-1218
Mailing Address - Fax:
Practice Address - Street 1:RR 5 BOX 8706
Practice Address - Street 2:
Practice Address - City:BAYAMON
Practice Address - State:PR
Practice Address - Zip Code:00956-9727
Practice Address - Country:US
Practice Address - Phone:787-428-1218
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-04
Last Update Date:2016-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR4149101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional