Provider Demographics
NPI:1790565612
Name:RODRIGUEZ, SANDRA I (LAC)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:I
Last Name:RODRIGUEZ
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43 LIBERTY ST
Mailing Address - Street 2:
Mailing Address - City:FORDS
Mailing Address - State:NJ
Mailing Address - Zip Code:08863-2214
Mailing Address - Country:US
Mailing Address - Phone:732-406-4857
Mailing Address - Fax:
Practice Address - Street 1:43 LIBERTY ST
Practice Address - Street 2:
Practice Address - City:FORDS
Practice Address - State:NJ
Practice Address - Zip Code:08863-2214
Practice Address - Country:US
Practice Address - Phone:732-406-4857
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-29
Last Update Date:2023-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37AC00671500101Y00000X
101YM0800X
37AC00671500101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor