Healthcare Provider Details

I. General information

NPI: 1730043928
Provider Name (Legal Business Name): KIMBERLY RODRIGUEZ LCADC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/11/2025
Last Update Date: 12/11/2025
Certification Date: 12/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

244 FILMORE ST
RIVERSIDE NJ
08075-3222
US

IV. Provider business mailing address

244 FILMORE ST
RIVERSIDE NJ
08075-3222
US

V. Phone/Fax

Practice location:
  • Phone: 856-209-4765
  • Fax: 856-209-4765
Mailing address:
  • Phone: 856-209-4765
  • Fax: 856-209-4765

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number37LC00356200
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: