Provider Demographics
NPI:1447674205
Name:RODRIGUEZ, MARIOLA
Entity type:Individual
Prefix:MRS
First Name:MARIOLA
Middle Name:
Last Name:RODRIGUEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1463 OAKFIELD DR STE 130
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-0802
Mailing Address - Country:US
Mailing Address - Phone:813-655-4166
Mailing Address - Fax:
Practice Address - Street 1:1463 OAKFIELD DR STE 130
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-0802
Practice Address - Country:US
Practice Address - Phone:813-655-4166
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-13
Last Update Date:2020-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
222Q00000X
PR5572103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool