Healthcare Provider Details

I. General information

NPI: 1568682631
Provider Name (Legal Business Name): MYRNA IRIS RODRIGUEZ PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/30/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8129 CALLE CONCORDIA CONDO. CONCORDIA SUITE502
PONCE PR
00717-1548
US

IV. Provider business mailing address

5009 PASEO CONSTANCIA HACIENDAS DEL MONTE
COTO LAUREL PR
00780-2372
US

V. Phone/Fax

Practice location:
  • Phone: 787-844-0125
  • Fax: 787-844-9019
Mailing address:
  • Phone: 787-848-1002
  • Fax: 787-844-9019

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number439
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: