Healthcare Provider Details

I. General information

NPI: 1063491991
Provider Name (Legal Business Name): MICHAEL DAMIEN RODRIGUEZ MSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/10/2006
Last Update Date: 12/02/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 HOSPITAL SOUTH DR SUITE 102
AUSTELL GA
30106-6810
US

IV. Provider business mailing address

1872 MONTREAL RD
TUCKER GA
30084-5709
US

V. Phone/Fax

Practice location:
  • Phone: 770-948-3233
  • Fax: 770-944-1537
Mailing address:
  • Phone: 770-496-9400
  • Fax: 770-496-9495

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0030804
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: