Provider Demographics
NPI:1396505426
Name:RODRIGUEZ, VICTOR JR (LAC)
Entity type:Individual
Prefix:MR
First Name:VICTOR
Middle Name:
Last Name:RODRIGUEZ
Suffix:JR
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 BEAUMONT PL
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07104-1611
Mailing Address - Country:US
Mailing Address - Phone:973-934-5377
Mailing Address - Fax:973-638-1120
Practice Address - Street 1:13 FAIRFIELD AVE
Practice Address - Street 2:
Practice Address - City:LITTLE FALLS
Practice Address - State:NJ
Practice Address - Zip Code:07424-1264
Practice Address - Country:US
Practice Address - Phone:973-638-1120
Practice Address - Fax:973-638-1126
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-19
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37AC00450800106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist