Provider Demographics
NPI:1689170821
Name:RODRIGUEZ, MATTHEW ROBERT
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:ROBERT
Last Name:RODRIGUEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:445 W WEBER AVE STE 129
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95203-3146
Mailing Address - Country:US
Mailing Address - Phone:209-451-3628
Mailing Address - Fax:
Practice Address - Street 1:445 W WEBER AVE STE 129
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95203-3146
Practice Address - Country:US
Practice Address - Phone:209-451-3628
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-05
Last Update Date:2018-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA390017BN101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)