Healthcare Provider Details

I. General information

NPI: 1962072389
Provider Name (Legal Business Name): STEPHANIE RODRIGUEZ MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2021
Last Update Date: 07/03/2023
Certification Date: 07/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

530 W BADILLO ST
COVINA CA
91722-3787
US

IV. Provider business mailing address

530 W BADILLO ST
COVINA CA
91722-3787
US

V. Phone/Fax

Practice location:
  • Phone: 626-993-3000
  • Fax:
Mailing address:
  • Phone: 626-993-3000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number103780
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number103780
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: