Healthcare Provider Details

I. General information

NPI: 1922852219
Provider Name (Legal Business Name): MARLENE GRACE RIVERA RODRIGUEZ PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/15/2024
Last Update Date: 08/05/2026
Certification Date: 08/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 MANCHESTER RD STE 301
WHEATON IL
60187-4584
US

IV. Provider business mailing address

2100 MANCHESTER RD STE 301
WHEATON IL
60187-4584
US

V. Phone/Fax

Practice location:
  • Phone: 601-871-0170
  • Fax:
Mailing address:
  • Phone: 601-871-0170
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number071011201
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: