Provider Demographics
NPI:1932660289
Name:RODRIQUEZ, RANDY
Entity Type:Individual
Prefix:
First Name:RANDY
Middle Name:
Last Name:RODRIQUEZ
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 1:150 SHOUP AVE STE 17
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83402-3653
Mailing Address - Country:US
Mailing Address - Phone:208-528-5700
Mailing Address - Fax:208-528-4747
Practice Address - Street 1:150 SHOUP AVE STE 17
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83402-3653
Practice Address - Country:US
Practice Address - Phone:208-528-5700
Practice Address - Fax:208-528-4747
Is Sole Proprietor?:No
Enumeration Date:2019-03-28
Last Update Date:2019-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID10831041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical