Healthcare Provider Details

I. General information

NPI: 1245056670
Provider Name (Legal Business Name): EFREN EMILIO RODRIGUEZ LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/02/2024
Last Update Date: 12/23/2024
Certification Date: 12/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4361 LATHAM ST STE 220
RIVERSIDE CA
92501-1767
US

IV. Provider business mailing address

4361 LATHAM ST STE 220
RIVERSIDE CA
92501-1767
US

V. Phone/Fax

Practice location:
  • Phone: 858-279-1223
  • Fax: 858-467-7161
Mailing address:
  • Phone: 858-279-1223
  • Fax: 858-467-7161

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number127507
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: