Provider Demographics
NPI:1750668075
Name:RODRIGUEZ, MANUEL D (BCABA)
Entity Type:Individual
Prefix:
First Name:MANUEL
Middle Name:D
Last Name:RODRIGUEZ
Suffix:
Gender:M
Credentials:BCABA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11930 AMARGOSA RD. SUITE 1
Mailing Address - Street 2:#1037
Mailing Address - City:VICTORVILLLE
Mailing Address - State:CA
Mailing Address - Zip Code:92392
Mailing Address - Country:US
Mailing Address - Phone:661-974-4496
Mailing Address - Fax:213-214-0629
Practice Address - Street 1:16713 ROSCOE BLVD
Practice Address - Street 2:
Practice Address - City:NORTH HILLS
Practice Address - State:CA
Practice Address - Zip Code:91343-6110
Practice Address - Country:US
Practice Address - Phone:800-418-9319
Practice Address - Fax:800-861-3759
Is Sole Proprietor?:No
Enumeration Date:2011-11-15
Last Update Date:2023-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-17-26630103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst