Healthcare Provider Details

I. General information

NPI: 1437257656
Provider Name (Legal Business Name): LARRY GODINEZ RODRIGUEZ MSW, CAADAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1020 IOWA AVE
RIVERSIDE CA
92507-2105
US

IV. Provider business mailing address

1050 S ARROWHEAD AVE
BLOOMINGTON CA
92316-1502
US

V. Phone/Fax

Practice location:
  • Phone: 950-955-3330
  • Fax: 951-955-3889
Mailing address:
  • Phone: 909-519-7597
  • Fax: 951-955-3889

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: