Healthcare Provider Details

I. General information

NPI: 1053147694
Provider Name (Legal Business Name): MIGUEL ADRIAN RODRIGUEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/10/2024
Last Update Date: 04/01/2026
Certification Date: 04/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

503 OCEAN FRONT WALK
VENICE CA
90291-2403
US

IV. Provider business mailing address

815 N EL CENTRO AVE
LOS ANGELES CA
90038-3805
US

V. Phone/Fax

Practice location:
  • Phone: 310-392-3070
  • Fax:
Mailing address:
  • Phone: 323-463-2119
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number21997
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number161660
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: