Provider Demographics
NPI:1962680306
Name:RODRIGUEZ, RAFAEL (LCSW)
Entity Type:Individual
Prefix:MR
First Name:RAFAEL
Middle Name:
Last Name:RODRIGUEZ
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1684 W 10TH ST APT F9
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11223-1170
Mailing Address - Country:US
Mailing Address - Phone:347-260-6778
Mailing Address - Fax:
Practice Address - Street 1:175 LAWRENCE AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11230-1102
Practice Address - Country:US
Practice Address - Phone:718-436-7600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-07
Last Update Date:2008-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY073633-1320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities