Provider Demographics
NPI:1356890248
Name:MERCADO, RODOLFO JESUS
Entity type:Individual
Prefix:
First Name:RODOLFO
Middle Name:JESUS
Last Name:MERCADO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:RUDY
Other - Middle Name:JESUS
Other - Last Name:MERCADO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:202 N 8TH ST
Mailing Address - Street 2:
Mailing Address - City:EL CENTRO
Mailing Address - State:CA
Mailing Address - Zip Code:92243-2302
Mailing Address - Country:US
Mailing Address - Phone:442-265-1525
Mailing Address - Fax:442-265-1638
Practice Address - Street 1:202 N 8TH ST
Practice Address - Street 2:
Practice Address - City:EL CENTRO
Practice Address - State:CA
Practice Address - Zip Code:92243-2302
Practice Address - Country:US
Practice Address - Phone:442-265-1525
Practice Address - Fax:442-265-1638
Is Sole Proprietor?:No
Enumeration Date:2016-10-03
Last Update Date:2024-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X, 225C00000X
CA1059611041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No225C00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Counselor