Provider Demographics
NPI:1790218741
Name:RODRIGUEZ GARCIA, GRISELL
Entity Type:Individual
Prefix:
First Name:GRISELL
Middle Name:
Last Name:RODRIGUEZ GARCIA
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 1:5800 SW 19TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33155-2146
Mailing Address - Country:US
Mailing Address - Phone:786-624-8574
Mailing Address - Fax:
Practice Address - Street 1:7855 NW 12TH ST STE 117
Practice Address - Street 2:
Practice Address - City:DORAL
Practice Address - State:FL
Practice Address - Zip Code:33126-1818
Practice Address - Country:US
Practice Address - Phone:305-742-2189
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-06
Last Update Date:2017-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL32848976Medicaid