Healthcare Provider Details

I. General information

NPI: 1114088291
Provider Name (Legal Business Name): MARY TERESA RODRIGUES LPCC/LADAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/13/2006
Last Update Date: 04/07/2025
Certification Date: 04/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4730 BECKNER RD
SANTA FE NM
87507-3691
US

IV. Provider business mailing address

4730 BECKNER RD
SANTA FE NM
87507-3691
US

V. Phone/Fax

Practice location:
  • Phone: 505-989-4500
  • Fax: 505-443-8313
Mailing address:
  • Phone: 59-894-5005
  • Fax: 54-438-3135

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCAD0163871
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0120871
License Number StateNM
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number1106 LCPC
License Number StateMT
# 4
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberCCMH0120871
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: