Provider Demographics
NPI:1952433153
Name:RODRIGUEZ, SAN JUANA SAN
Entity type:Individual
Prefix:MRS
First Name:SAN JUANA
Middle Name:SAN
Last Name:RODRIGUEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JUANA
Other - Middle Name:SAN
Other - Last Name:RAMIREZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 177
Mailing Address - Street 2:
Mailing Address - City:AURELIA
Mailing Address - State:IA
Mailing Address - Zip Code:51005-0177
Mailing Address - Country:US
Mailing Address - Phone:712-299-2182
Mailing Address - Fax:
Practice Address - Street 1:1824 FLINT DRIVE
Practice Address - Street 2:SUITE 104
Practice Address - City:STORM LAKE
Practice Address - State:IA
Practice Address - Zip Code:50558
Practice Address - Country:US
Practice Address - Phone:712-262-2922
Practice Address - Fax:712-262-3826
Is Sole Proprietor?:No
Enumeration Date:2007-03-12
Last Update Date:2024-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAT24011101YA0400X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171M00000XOther Service ProvidersCase Manager/Care Coordinator