Healthcare Provider Details

I. General information

NPI: 1770362212
Provider Name (Legal Business Name): TYESHA RODRIGUEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2023
Last Update Date: 09/25/2023
Certification Date: 09/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8G PASCO DR
EAST WINDSOR CT
06088-1708
US

IV. Provider business mailing address

80 ELLINGTON ST
HARTFORD CT
06106-3454
US

V. Phone/Fax

Practice location:
  • Phone: 860-254-5127
  • Fax:
Mailing address:
  • Phone: 860-849-3042
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number9028
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: