Healthcare Provider Details

I. General information

NPI: 1457191918
Provider Name (Legal Business Name): KATHLEEN RODRIGUEZ SUDRC #18376
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/30/2024
Last Update Date: 12/16/2024
Certification Date: 12/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7344 MAGNOLIA AVE STE 110
RIVERSIDE CA
92504-3819
US

IV. Provider business mailing address

7344 MAGNOLIA AVE STE 110
RIVERSIDE CA
92504-3819
US

V. Phone/Fax

Practice location:
  • Phone: 951-480-0856
  • Fax: 951-755-8856
Mailing address:
  • Phone: 951-404-0856
  • Fax: 951-755-8856

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number18376
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number18376
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateCA
# 5
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: