Provider Demographics
NPI:1770320939
Name:RODRIGUEZ, WANDA YVETTE
Entity type:Individual
Prefix:
First Name:WANDA
Middle Name:YVETTE
Last Name:RODRIGUEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1456 DWIGHT ST
Mailing Address - Street 2:
Mailing Address - City:HOLYOKE
Mailing Address - State:MA
Mailing Address - Zip Code:01040-2355
Mailing Address - Country:US
Mailing Address - Phone:413-204-3008
Mailing Address - Fax:
Practice Address - Street 1:1456 DWIGHT ST
Practice Address - Street 2:
Practice Address - City:HOLYOKE
Practice Address - State:MA
Practice Address - Zip Code:01040-2355
Practice Address - Country:US
Practice Address - Phone:413-204-3008
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-13
Last Update Date:2024-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
MA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Multi-Specialty