Provider Demographics
NPI:1750463790
Name:RODRIGUEZ, CARRIE ANN (MA, CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:CARRIE
Middle Name:ANN
Last Name:RODRIGUEZ
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2519 MAIDEN GRASS RD NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87120-6239
Mailing Address - Country:US
Mailing Address - Phone:505-362-1469
Mailing Address - Fax:505-352-9213
Practice Address - Street 1:2519 MAIDEN GRASS RD NW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87120-6239
Practice Address - Country:US
Practice Address - Phone:505-362-1469
Practice Address - Fax:505-352-9213
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2687174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMB5608Medicaid