Provider Demographics
NPI:1700830569
Name:RODRIGUEZ, REBECCA DIANE (PHD)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:DIANE
Last Name:RODRIGUEZ
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:464 DALY AVE
Mailing Address - Street 2:
Mailing Address - City:WISCONSIN RAPIDS
Mailing Address - State:WI
Mailing Address - Zip Code:54494-4746
Mailing Address - Country:US
Mailing Address - Phone:715-423-2030
Mailing Address - Fax:715-423-2032
Practice Address - Street 1:464 DALY AVE
Practice Address - Street 2:
Practice Address - City:WISCONSIN RAPIDS
Practice Address - State:WI
Practice Address - Zip Code:54494-4746
Practice Address - Country:US
Practice Address - Phone:715-423-2030
Practice Address - Fax:715-423-2032
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-19
Last Update Date:2010-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2237057103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIPO6153Medicare UPIN
WI000072002Medicare PIN