Healthcare Provider Details

I. General information

NPI: 1639006836
Provider Name (Legal Business Name): KANDISS RODRIGUEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/04/2026
Last Update Date: 05/04/2026
Certification Date: 05/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 PASADENA AVE
SOUTH PASADENA CA
91030-2919
US

IV. Provider business mailing address

205 PASADENA AVE
SOUTH PASADENA CA
91030-2919
US

V. Phone/Fax

Practice location:
  • Phone: 323-344-5536
  • Fax: 323-344-5536
Mailing address:
  • Phone: 323-344-5536
  • Fax: 323-344-5536

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number124684
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: