Provider Demographics
NPI:1952772014
Name:RODRIGUEZ, MARCUS (PHD)
Entity Type:Individual
Prefix:
First Name:MARCUS
Middle Name:
Last Name:RODRIGUEZ
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1849 SAWTELLE BLVD STE 610
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-7013
Mailing Address - Country:US
Mailing Address - Phone:323-800-8882
Mailing Address - Fax:
Practice Address - Street 1:1849 SAWTELLE BLVD STE 610
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-7013
Practice Address - Country:US
Practice Address - Phone:323-800-8883
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-15
Last Update Date:2023-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA32571103TC2200X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent