Provider Demographics
NPI:1669109914
Name:PACHECO, RODOLFO ANTHONY (LLMSW)
Entity type:Individual
Prefix:
First Name:RODOLFO
Middle Name:ANTHONY
Last Name:PACHECO
Suffix:
Gender:M
Credentials:LLMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22866 LONGACRE ST
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48335-4055
Mailing Address - Country:US
Mailing Address - Phone:937-626-3943
Mailing Address - Fax:
Practice Address - Street 1:1255 N OAKLAND BLVD
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:MI
Practice Address - Zip Code:48327-1545
Practice Address - Country:US
Practice Address - Phone:248-461-2910
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-05
Last Update Date:2022-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68511146141041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical