Provider Demographics
NPI:1811463243
Name:RODRIGUEZ, LOURDES M
Entity type:Individual
Prefix:
First Name:LOURDES
Middle Name:M
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 1:13512 INLET LN APT 208
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32824-5102
Mailing Address - Country:US
Mailing Address - Phone:407-692-4170
Mailing Address - Fax:
Practice Address - Street 1:13512 INLET LN APT 208
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32824-5102
Practice Address - Country:US
Practice Address - Phone:407-692-4170
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-24
Last Update Date:2018-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLRBT-16-24746OtherREGISTER BEHAVIOR TECHNICIAN
FL017577600Medicaid