Provider Demographics
NPI:1689276263
Name:RODRIGUEZ, KIRA SUE (LISW, LCDC III)
Entity Type:Individual
Prefix:
First Name:KIRA
Middle Name:SUE
Last Name:RODRIGUEZ
Suffix:
Gender:F
Credentials:LISW, LCDC III
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 W MADISON ST
Mailing Address - Street 2:
Mailing Address - City:GIBSONBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43431-1221
Mailing Address - Country:US
Mailing Address - Phone:567-201-6450
Mailing Address - Fax:
Practice Address - Street 1:400 W MADISON ST
Practice Address - Street 2:
Practice Address - City:GIBSONBURG
Practice Address - State:OH
Practice Address - Zip Code:43431-1221
Practice Address - Country:US
Practice Address - Phone:567-201-6450
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-10
Last Update Date:2020-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.1901397101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health