Provider Demographics
NPI:1811322969
Name:CARLOS RODRIGUEZ, PH.D., P.C.
Entity type:Organization
Organization Name:CARLOS RODRIGUEZ, PH.D., P.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:CARLOS
Authorized Official - Middle Name:JOSE
Authorized Official - Last Name:RODRIGUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:719-545-5211
Mailing Address - Street 1:PO BOX 3336
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81005-0336
Mailing Address - Country:US
Mailing Address - Phone:719-545-5211
Mailing Address - Fax:719-545-1962
Practice Address - Street 1:1301 W 17TH ST
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81003-1915
Practice Address - Country:US
Practice Address - Phone:719-545-5211
Practice Address - Fax:719-545-1962
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-09
Last Update Date:2013-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1004103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO07109952Medicaid
COC96316Medicare PIN