Healthcare Provider Details

I. General information

NPI: 1184097495
Provider Name (Legal Business Name): MAYRA RODRIGUEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2015
Last Update Date: 03/25/2021
Certification Date: 03/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1540 E COLORADO ST
GLENDALE CA
91205-1514
US

IV. Provider business mailing address

4760 SEPULVEDA BLVD
CULVER CITY CA
90230-4820
US

V. Phone/Fax

Practice location:
  • Phone: 818-244-7257
  • Fax: 818-243-5431
Mailing address:
  • Phone: 310-390-6612
  • Fax: 310-398-5690

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLCSW88831
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberASW72266
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: