Healthcare Provider Details

I. General information

NPI: 1588499065
Provider Name (Legal Business Name): MAXX RODRIGUEX
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/04/2024
Last Update Date: 06/24/2026
Certification Date: 06/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1303 SAN CARLOS AVE
SAN CARLOS CA
94070-2317
US

IV. Provider business mailing address

1303 SAN CARLOS AVE
SAN CARLOS CA
94070-2317
US

V. Phone/Fax

Practice location:
  • Phone: 650-394-5155
  • Fax:
Mailing address:
  • Phone: 650-394-5155
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number164039
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number23004
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: