Provider Demographics
NPI:1790200376
Name:RODRIGUEZ, LAURA
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:RODRIGUEZ
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 1:280 RIVER RD APT 80B
Mailing Address - Street 2:
Mailing Address - City:PISCATAWAY
Mailing Address - State:NJ
Mailing Address - Zip Code:08854-3563
Mailing Address - Country:US
Mailing Address - Phone:646-725-0508
Mailing Address - Fax:
Practice Address - Street 1:21 32 78TH STREET #1
Practice Address - Street 2:
Practice Address - City:EAST ELMHURST
Practice Address - State:NY
Practice Address - Zip Code:11370
Practice Address - Country:US
Practice Address - Phone:347-941-0030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-04
Last Update Date:2021-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010422101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health