Provider Demographics
NPI:1932112513
Name:RODRIGUEZ, MICHAEL ROBERT (PHD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ROBERT
Last Name:RODRIGUEZ
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3900 JUAN TABO BLVD NE
Mailing Address - Street 2:SUITE 12
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87111-3984
Mailing Address - Country:US
Mailing Address - Phone:505-275-6405
Mailing Address - Fax:
Practice Address - Street 1:3900 JUAN TABO BLVD NE
Practice Address - Street 2:SUITE 12
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87111-3984
Practice Address - Country:US
Practice Address - Phone:505-275-6405
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM268103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist