Provider Demographics
NPI:1912603473
Name:RODRIGUEZ, SAMUEL KALEB
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:KALEB
Last Name:RODRIGUEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2744 HERWALD ST
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34231-5116
Mailing Address - Country:US
Mailing Address - Phone:941-250-9458
Mailing Address - Fax:
Practice Address - Street 1:350 BRADEN AVE
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34243-2001
Practice Address - Country:US
Practice Address - Phone:941-355-7637
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-06
Last Update Date:2023-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician