Provider Demographics
NPI:1801187455
Name:RODRIGUEZ, RAISA
Entity Type:Individual
Prefix:
First Name:RAISA
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 1:11402 MOUNTAIN BAY DR
Mailing Address - Street 2:
Mailing Address - City:RIVERVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:33569-2039
Mailing Address - Country:US
Mailing Address - Phone:813-443-9167
Mailing Address - Fax:
Practice Address - Street 1:708 PEARL CIR
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33510-4246
Practice Address - Country:US
Practice Address - Phone:813-391-0235
Practice Address - Fax:813-655-4814
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-29
Last Update Date:2011-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist