Provider Demographics
NPI:1396136347
Name:RODRIGUEZ, SAMANTHA
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:RODRIGUEZ
Suffix:
Gender:F
Credentials:
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 33568
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92163-3568
Mailing Address - Country:US
Mailing Address - Phone:855-223-7123
Mailing Address - Fax:619-374-7134
Practice Address - Street 1:12409 W INDIAN SCHOOL RD STE B210
Practice Address - Street 2:
Practice Address - City:AVONDALE
Practice Address - State:AZ
Practice Address - Zip Code:85392-9505
Practice Address - Country:US
Practice Address - Phone:855-223-7123
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-12
Last Update Date:2025-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLPA92412355S0801X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant