Provider Demographics
NPI:1790960201
Name:RODRIGUEZ, MILDRED MICHELLE (MS, LPC, LMFT-A, CSC)
Entity Type:Individual
Prefix:MS
First Name:MILDRED
Middle Name:MICHELLE
Last Name:RODRIGUEZ
Suffix:
Gender:F
Credentials:MS, LPC, LMFT-A, CSC
Other - Prefix:MISS
Other - First Name:MILDRED
Other - Middle Name:MICHELLE
Other - Last Name:WILLIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, LPC, LMFT, CSC
Mailing Address - Street 1:815 WILLOW AVE
Mailing Address - Street 2:
Mailing Address - City:SULPHUR
Mailing Address - State:LA
Mailing Address - Zip Code:70663-3420
Mailing Address - Country:US
Mailing Address - Phone:337-313-3108
Mailing Address - Fax:337-313-3347
Practice Address - Street 1:815 WILLOW AVE
Practice Address - Street 2:
Practice Address - City:SULPHUR
Practice Address - State:LA
Practice Address - Zip Code:70663-3420
Practice Address - Country:US
Practice Address - Phone:337-313-3108
Practice Address - Fax:337-313-3347
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-02
Last Update Date:2014-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX64352101YP2500X
TX201608106H00000X
101YS0200X
LA4855101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool