Provider Demographics
NPI:1750397741
Name:RODRIGUEZ, ROGELIO ESTRADA (PHD)
Entity type:Individual
Prefix:DR
First Name:ROGELIO
Middle Name:ESTRADA
Last Name:RODRIGUEZ
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3019 COIT AVE NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49505-3376
Mailing Address - Country:US
Mailing Address - Phone:616-365-9575
Mailing Address - Fax:
Practice Address - Street 1:3019 COIT AVE NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49505-3376
Practice Address - Country:US
Practice Address - Phone:616-365-9575
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301011625103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical