Basic Information
| Provider Information | |||||||||
| NPI: | 1144247859 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MARIA A RODRIGUEZ, PH.D. | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 417 W 13TH ST | ||||||||
| Address2: | |||||||||
| City: | PUEBLO | ||||||||
| State: | CO | ||||||||
| PostalCode: | 810032703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195440877 | ||||||||
| FaxNumber: | 7195442033 | ||||||||
| Practice Location | |||||||||
| Address1: | 417 W 13TH ST | ||||||||
| Address2: | |||||||||
| City: | PUEBLO | ||||||||
| State: | CO | ||||||||
| PostalCode: | 810032703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195440877 | ||||||||
| FaxNumber: | 7195442033 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2006 | ||||||||
| LastUpdateDate: | 11/01/2007 | ||||||||
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| AuthorizedOfficialLastName: | RODRIGUEZ | ||||||||
| AuthorizedOfficialFirstName: | MARIA | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7195440877 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | PH.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 69381810 | 05 | CO | MEDICAID |