Healthcare Provider Details

I. General information

NPI: 1295851491
Provider Name (Legal Business Name): ANTONIO RODRIGUEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2007
Last Update Date: 02/06/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5810 RALSTON ST
VENTURA CA
93003-6010
US

IV. Provider business mailing address

1062 GRACIA ST
CAMARILLO CA
93010-3942
US

V. Phone/Fax

Practice location:
  • Phone: 805-642-7033
  • Fax: 805-642-7732
Mailing address:
  • Phone: 805-415-3752
  • Fax:

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: