Basic Information
Provider Information | |||||||||
NPI: | 1821341199 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | RODRIGUEZ | ||||||||
FirstName: | MELISSA | ||||||||
MiddleName: | NOEMY | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | AMFT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1487 HUNTINGTON AVE | ||||||||
Address2: |   | ||||||||
City: | SOUTH SAN FRANCISCO | ||||||||
State: | CA | ||||||||
PostalCode: | 940801355 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6504549340 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 31 TOWER ROAD | ||||||||
Address2: |   | ||||||||
City: | SAN MATEO | ||||||||
State: | CA | ||||||||
PostalCode: | 94402 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6503125320 | ||||||||
FaxNumber: | 6505722414 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/23/2012 | ||||||||
LastUpdateDate: | 01/29/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/29/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X |   |   | N |   | Behavioral Health & Social Service Providers | Counselor | Mental Health | 106H00000X | AMFT80341 | CA | Y |   | Behavioral Health & Social Service Providers | Marriage & Family Therapist |   |
No ID Information.