Provider Demographics
NPI:1699216580
Name:RODRIGUEZ, JOSE (LCSW)
Entity Type:Individual
Prefix:MR
First Name:JOSE
Middle Name:
Last Name:RODRIGUEZ
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 W 10TH AVE
Mailing Address - Street 2:P. O. BOX 2145
Mailing Address - City:OSHKOSH
Mailing Address - State:WI
Mailing Address - Zip Code:54903-2145
Mailing Address - Country:US
Mailing Address - Phone:920-886-9319
Mailing Address - Fax:920-886-9357
Practice Address - Street 1:1478 KENWOOD DR
Practice Address - Street 2:SUITE 1
Practice Address - City:MENASHA
Practice Address - State:WI
Practice Address - Zip Code:54952-1161
Practice Address - Country:US
Practice Address - Phone:920-886-9319
Practice Address - Fax:920-886-9357
Is Sole Proprietor?:No
Enumeration Date:2017-03-13
Last Update Date:2017-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI12601101YA0400X
WI278101YP2500X
WI18831041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional