MEDICARE: SAMANTHA JACKELYN 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	103K00000X	Behavior Analyst

General Provider Information

NPI Number	:	1902450547
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SAMANTHA JACKELYN RODRIGUEZ

Provider Business Mailing Address
First Line	:	21600 OXNARD ST STE 1800
Second Line	:
City	:	WOODLAND HILLS
State	:	CA
Zip	:	91367-7807
Country	:	US
Telephone Number	:	818-345-2345
Fax Number	:

Provider Business Practice Location Address
First Line	:	115 S MARION ST
Second Line	:
City	:	OAK PARK
State	:	IL
Zip	:	60302-2826
Country	:	US
Telephone Number	:	708-358-3000
Fax Number	:

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

Provider Enumeration Date	:	07/31/2019
Last Update Date	:	07/31/2019

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