Basic Information
| Provider Information | |||||||||
| NPI: | 1821696675 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RODRIGUEZ | ||||||||
| FirstName: | BUNNY | ||||||||
| MiddleName: | CATHERINA | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.S.W., L.A.D.C. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 60 LAKE RD | ||||||||
| Address2: | |||||||||
| City: | NORTH BRANFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064711252 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2038431915 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 54 E RAMSDELL ST | ||||||||
| Address2: | |||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065151140 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2033379943 | ||||||||
| FaxNumber: | 2033374395 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/14/2020 | ||||||||
| LastUpdateDate: | 01/24/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/24/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 1389 | CT | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 008039745 | 05 | CT | MEDICAID | 008023170 | 05 | CT | MEDICAID | 008024427 | 05 | CT | MEDICAID | 008042339 | 05 | CT | MEDICAID |