Provider Demographics
NPI:1649699851
Name:RODRIGUEZ, EVELYN (MED)
Entity type:Individual
Prefix:
First Name:EVELYN
Middle Name:
Last Name:RODRIGUEZ
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:141 E MAIN ST
Mailing Address - Street 2:4TH FLOOR ADMINISTRATION
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06702-2310
Mailing Address - Country:US
Mailing Address - Phone:203-574-9000
Mailing Address - Fax:203-574-9006
Practice Address - Street 1:141 E MAIN ST
Practice Address - Street 2:3RD FLOOR HOME BASED SERVICES
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06702-2310
Practice Address - Country:US
Practice Address - Phone:203-575-0466
Practice Address - Fax:203-575-1817
Is Sole Proprietor?:No
Enumeration Date:2014-04-15
Last Update Date:2016-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1777104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTPROVISIONAL EDUCATOROtherBLOOMFIELD SCHOOL DISTRICT-PROVISIONAL EDUCATOR
CT008062548Medicaid
CT13671482OtherCAQH
CT060669107OtherUBH-OXFORD HEALTH FREEDOM/LIBERTY WELLMORE GRP/FACILITY
CT060669107OtherUBH-UNITED HEALTH CARE WELLMORE GRP/FACILITY
CT060669107OtherHEALTHYCT WELLMORE GRP/FACILITY
CTPENDINGOtherCIGNA BEHAVIORAL HEALTH
CTD339209-141 E MAINOtherVALUE OPTIONS
CTNOT ELIGIBLEOtherMHN TRICARE NORTH
CT008062548Medicaid
CTNOT ELIGIBLEOtherMHN MANAGED HEALTH NETWORK
CT060669107OtherUBH-CONNECTICARE WELLMORE GRP/FACILITY
CTNOT ELIGIBLEMedicare PIN
CT13671482OtherCAQH
CTPENDINGOtherAETNA BEHAVIORAL HEALTH