Healthcare Provider Details

I. General information

NPI: 1750397741
Provider Name (Legal Business Name): ROGELIO ESTRADA RODRIGUEZ PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2006
Last Update Date: 08/11/2025
Certification Date: 08/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3019 COIT AVE NE
GRAND RAPIDS MI
49505-3376
US

IV. Provider business mailing address

5838 METRO WAY SW
WYOMING MI
49519-9619
US

V. Phone/Fax

Practice location:
  • Phone: 616-365-9575
  • Fax:
Mailing address:
  • Phone: 616-249-5300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6301011625
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: