Provider Demographics
NPI:1245525625
Name:RODRIGUEZ, BETHANIE DIANE (OTR/L)
Entity type:Individual
Prefix:MRS
First Name:BETHANIE
Middle Name:DIANE
Last Name:RODRIGUEZ
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:MISS
Other - First Name:BETHANIE
Other - Middle Name:DIANE
Other - Last Name:WATERMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR/L
Mailing Address - Street 1:1130 SUNNY LN
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48638-5643
Mailing Address - Country:US
Mailing Address - Phone:989-233-0097
Mailing Address - Fax:
Practice Address - Street 1:1130 SUNNY LN
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48638-5643
Practice Address - Country:US
Practice Address - Phone:989-233-0097
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-14
Last Update Date:2011-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201007345172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker