MEDICARE: ALYSSA NICOLE RODRIGUEZ

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician
2	106S00000X	Behavior Technician	RBT-22-229552

General Provider Information

NPI Number	:	1629796024
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ALYSSA NICOLE RODRIGUEZ

Provider Business Mailing Address
First Line	:	218 GRANGE RD
Second Line	:
City	:	OTISVILLE
State	:	NY
Zip	:	10963-3112
Country	:	US
Telephone Number	:	646-382-1199
Fax Number	:

Provider Business Practice Location Address
First Line	:	118 RIVER RD
Second Line	:
City	:	HARRIMAN
State	:	NY
Zip	:	10926-3021
Country	:	US
Telephone Number	:	845-863-5208
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/22/2022
Last Update Date	:	08/26/2022

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