Healthcare Provider Details

I. General information

NPI: 1265146765
Provider Name (Legal Business Name): NICHOLAS RYAN RODRIGUEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/09/2023
Last Update Date: 05/12/2026
Certification Date: 05/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

840 N AVENUE 66
LOS ANGELES CA
90042-1508
US

IV. Provider business mailing address

840 N AVENUE 66
LOS ANGELES CA
90042-1508
US

V. Phone/Fax

Practice location:
  • Phone: 626-517-2368
  • Fax: 626-395-7270
Mailing address:
  • Phone: 626-517-2368
  • Fax: 626-395-7270

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number21891
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: