Provider Demographics
NPI:1457191918
Name:RODRIGUEZ, KATHLEEN (SUDRC #18376)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:RODRIGUEZ
Suffix:
Gender:F
Credentials:SUDRC #18376
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7344 MAGNOLIA AVE STE 110
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92504-3819
Mailing Address - Country:US
Mailing Address - Phone:951-404-0856
Mailing Address - Fax:951-755-8856
Practice Address - Street 1:7344 MAGNOLIA AVE STE 110
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92504-3819
Practice Address - Country:US
Practice Address - Phone:951-480-0856
Practice Address - Fax:951-755-8856
Is Sole Proprietor?:No
Enumeration Date:2024-05-30
Last Update Date:2024-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA18376101Y00000X, 101YA0400X
171400000X
CA171M00000X, 172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171400000XOther Service ProvidersHealth & Wellness Coach
No171M00000XOther Service ProvidersCase Manager/Care Coordinator