Basic Information
| Provider Information | |||||||||
| NPI: | 1093337834 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RODRIGUEZ | ||||||||
| FirstName: | QUILVIO | ||||||||
| MiddleName: | ANTONIO | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | PMHNP-BC, RN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4419 3RD AVE | ||||||||
| Address2: | |||||||||
| City: | BRONX | ||||||||
| State: | NY | ||||||||
| PostalCode: | 104572562 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7183647700 | ||||||||
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| Practice Location | |||||||||
| Address1: | 154 W 127TH ST | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100273739 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2127493507 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/14/2020 | ||||||||
| LastUpdateDate: | 01/13/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 01/13/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WP0809X | 703575 | NY | N | Nursing Service Providers | Registered Nurse | Psych/Mental Health, Adult | 363LP0808X | F403045-01 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 703575 | 05 | NY | MEDICAID |