Provider Demographics
NPI:1356579577
Name:RODRIGUEZ, AGNES DAWN (PROVISIONAL LISW)
Entity type:Individual
Prefix:MISS
First Name:AGNES
Middle Name:DAWN
Last Name:RODRIGUEZ
Suffix:
Gender:F
Credentials:PROVISIONAL LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 553
Mailing Address - Street 2:
Mailing Address - City:HI RLS MTN PK
Mailing Address - State:NM
Mailing Address - Zip Code:88325-0553
Mailing Address - Country:US
Mailing Address - Phone:575-443-6166
Mailing Address - Fax:575-437-0755
Practice Address - Street 1:2150 HIGHWAY 54 S
Practice Address - Street 2:
Practice Address - City:ALAMOGORDO
Practice Address - State:NM
Practice Address - Zip Code:88310-7330
Practice Address - Country:US
Practice Address - Phone:575-443-8133
Practice Address - Fax:575-443-8055
Is Sole Proprietor?:No
Enumeration Date:2009-06-25
Last Update Date:2021-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMI-071111041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical