Provider Demographics
NPI:1710752530
Name:RODRIGUEZ REY, KATINA MARLOVA
Entity Type:Individual
Prefix:
First Name:KATINA
Middle Name:MARLOVA
Last Name:RODRIGUEZ REY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:218 NW 92ND ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI SHORES
Mailing Address - State:FL
Mailing Address - Zip Code:33150-2231
Mailing Address - Country:US
Mailing Address - Phone:768-203-8797
Mailing Address - Fax:
Practice Address - Street 1:218 NW 92ND ST
Practice Address - Street 2:
Practice Address - City:MIAMI SHORES
Practice Address - State:FL
Practice Address - Zip Code:33150-2231
Practice Address - Country:US
Practice Address - Phone:768-203-8797
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-21
Last Update Date:2023-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-23-311886106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty