Provider Demographics
NPI:1780408997
Name:RODRIGUEZ, SHANTAL ENEDINA
Entity type:Individual
Prefix:
First Name:SHANTAL
Middle Name:ENEDINA
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 1:540 AUDUBON AVE APT 59
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10040-3305
Mailing Address - Country:US
Mailing Address - Phone:646-852-5834
Mailing Address - Fax:
Practice Address - Street 1:11655 QUEENS BLVD
Practice Address - Street 2:
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-7025
Practice Address - Country:US
Practice Address - Phone:917-403-8211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-13
Last Update Date:2024-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst