Healthcare Provider Details

I. General information

NPI: 1316072937
Provider Name (Legal Business Name): MOISES WILFREDO RODRIGUEZ PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/22/2007
Last Update Date: 09/29/2026
Certification Date: 09/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2227 S ATLANTIC BLVD # 306
MONTEREY PARK CA
91754-6803
US

IV. Provider business mailing address

2227 S ATLANTIC BLVD # 306
MONTEREY PARK CA
91754-6803
US

V. Phone/Fax

Practice location:
  • Phone: 310-460-9232
  • Fax:
Mailing address:
  • Phone: 310-460-9232
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number22593
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: