Provider Demographics
NPI:1891047841
Name:RODRIGUEZ, MAURICIO (MED)
Entity Type:Individual
Prefix:
First Name:MAURICIO
Middle Name:
Last Name:RODRIGUEZ
Suffix:
Gender:M
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:809 GOVERNORS AVE
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32808-7026
Mailing Address - Country:US
Mailing Address - Phone:407-375-4748
Mailing Address - Fax:
Practice Address - Street 1:668 N ORLANDO AVE
Practice Address - Street 2:SUITE 210
Practice Address - City:MAITLAND
Practice Address - State:FL
Practice Address - Zip Code:32751-4473
Practice Address - Country:US
Practice Address - Phone:407-261-0523
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-15
Last Update Date:2012-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLR362540654070101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor