Healthcare Provider Details

I. General information

NPI: 1457078487
Provider Name (Legal Business Name): CAROLINE RODRIGUEZ PSY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/20/2022
Last Update Date: 10/20/2022
Certification Date: 10/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4000 MACARTHUR BLVD STE 600
NEWPORT BEACH CA
92660-2517
US

IV. Provider business mailing address

375 CAMINO DE LA REINA APT 340
SAN DIEGO CA
92108-3198
US

V. Phone/Fax

Practice location:
  • Phone: 949-432-9173
  • Fax:
Mailing address:
  • Phone: 314-250-7890
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License Number2016008719
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number29214
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: