Provider Demographics
NPI:1669125852
Name:ROA RODRIGUEZ, RAFAEL (LMSW)
Entity type:Individual
Prefix:
First Name:RAFAEL
Middle Name:
Last Name:ROA RODRIGUEZ
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:311 E 175TH ST
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10457-5848
Mailing Address - Country:US
Mailing Address - Phone:718-960-7568
Mailing Address - Fax:
Practice Address - Street 1:262 E 174TH ST
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10457-7152
Practice Address - Country:US
Practice Address - Phone:718-299-6910
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-28
Last Update Date:2024-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY113614104100000X
NY0969701041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker