Provider Demographics
NPI:1750990453
Name:RODRIGUEZ, CARLY RENEE (LCSW)
Entity type:Individual
Prefix:MRS
First Name:CARLY
Middle Name:RENEE
Last Name:RODRIGUEZ
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:CARLY
Other - Middle Name:RENEE
Other - Last Name:DETTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:2860 S CIRCLE DR STE 109
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80906-4195
Mailing Address - Country:US
Mailing Address - Phone:719-540-2146
Mailing Address - Fax:
Practice Address - Street 1:2860 S CIRCLE DR STE 109
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80906-4195
Practice Address - Country:US
Practice Address - Phone:719-540-2146
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-28
Last Update Date:2022-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO.0009922168104100000X
COCSW.099268041041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker