Healthcare Provider Details

I. General information

NPI: 1356916043
Provider Name (Legal Business Name): ELEANOR AGOSTA RODRIGUEZ MSW, LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: ELLE AGOSTA MSW

II. Dates (important events)

Enumeration Date: 05/25/2021
Last Update Date: 12/19/2023
Certification Date: 12/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2113 RUBY RED BLVD STE D
CLERMONT FL
34714-6115
US

IV. Provider business mailing address

659 RESTON PL
DAVENPORT FL
33897-1626
US

V. Phone/Fax

Practice location:
  • Phone: 352-394-0573
  • Fax:
Mailing address:
  • Phone: 727-992-0070
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberSW21921
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: