Provider Demographics
NPI:1891342069
Name:RODRIGUEZ, BERTO OMAR SR
Entity Type:Individual
Prefix:
First Name:BERTO
Middle Name:OMAR
Last Name:RODRIGUEZ
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10477 SW 216TH ST APT 205
Mailing Address - Street 2:
Mailing Address - City:CUTLER BAY
Mailing Address - State:FL
Mailing Address - Zip Code:33190-1636
Mailing Address - Country:US
Mailing Address - Phone:786-406-0804
Mailing Address - Fax:
Practice Address - Street 1:10477 SW 216TH ST APT 205
Practice Address - Street 2:
Practice Address - City:CUTLER BAY
Practice Address - State:FL
Practice Address - Zip Code:33190-1636
Practice Address - Country:US
Practice Address - Phone:786-406-0804
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-22
Last Update Date:2019-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty