Healthcare Provider Details

I. General information

NPI: 1306266218
Provider Name (Legal Business Name): KOURTNEY L RODRIGUEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2014
Last Update Date: 06/24/2026
Certification Date: 06/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6316 GAINSBOROUGH DR
RALEIGH NC
27612-6615
US

IV. Provider business mailing address

6316 GAINSBOROUGH DR
RALEIGH NC
27612-6615
US

V. Phone/Fax

Practice location:
  • Phone: 207-323-1276
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number30004579
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: