Healthcare Provider Details

I. General information

NPI: 1386578409
Provider Name (Legal Business Name): MIRA JAN RODRIGUEZ-BRENT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2026
Last Update Date: 06/12/2026
Certification Date: 06/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1255 E RIVERSIDE DR
IONIA MI
48846-8604
US

IV. Provider business mailing address

1255 E RIVERSIDE DR
IONIA MI
48846-8604
US

V. Phone/Fax

Practice location:
  • Phone: 269-804-5797
  • Fax:
Mailing address:
  • Phone: 269-804-5797
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: