Provider Demographics
NPI:1922852219
Name:RIVERA RODRIGUEZ, MARLENE GRACE (PSYD)
Entity Type:Individual
Prefix:DR
First Name:MARLENE
Middle Name:GRACE
Last Name:RIVERA RODRIGUEZ
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1660 FEEHANVILLE DR
Mailing Address - Street 2:
Mailing Address - City:MT PROSPECT
Mailing Address - State:IL
Mailing Address - Zip Code:60056-6019
Mailing Address - Country:US
Mailing Address - Phone:847-981-9200
Mailing Address - Fax:
Practice Address - Street 1:1660 FEEHANVILLE DR
Practice Address - Street 2:
Practice Address - City:MT PROSPECT
Practice Address - State:IL
Practice Address - Zip Code:60056-6019
Practice Address - Country:US
Practice Address - Phone:847-981-9200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-15
Last Update Date:2024-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071011201103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical