Provider Demographics
NPI:1487527792
Name:RODRIGUEZ, ELIZABETH BREANNA
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:BREANNA
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 1:351 LORI ANN ST
Mailing Address - Street 2:
Mailing Address - City:SAN JACINTO
Mailing Address - State:CA
Mailing Address - Zip Code:92582-3154
Mailing Address - Country:US
Mailing Address - Phone:951-591-9811
Mailing Address - Fax:
Practice Address - Street 1:11748 MAGNOLIA AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92503-7123
Practice Address - Country:US
Practice Address - Phone:951-440-6220
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-24
Last Update Date:2025-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA103K00000K103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty