Healthcare Provider Details

I. General information

NPI: 1275106247
Provider Name (Legal Business Name): MICHAEL ANGELO RODRIGUEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2021
Last Update Date: 07/19/2021
Certification Date: 07/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1657 W CORTLAND ST
CHICAGO IL
60622-1119
US

IV. Provider business mailing address

950 LEE ST STE 210
DES PLAINES IL
60016-6574
US

V. Phone/Fax

Practice location:
  • Phone: 847-486-4140
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: