Healthcare Provider Details

I. General information

NPI: 1649884248
Provider Name (Legal Business Name): JOSE G. CRUZ RODRIGUEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/02/2020
Last Update Date: 06/17/2025
Certification Date: 06/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1020 PARK AVE
CRANSTON RI
02910-3227
US

IV. Provider business mailing address

66 PLANET AVE
RIVERSIDE RI
02915-2172
US

V. Phone/Fax

Practice location:
  • Phone: 401-396-7649
  • Fax:
Mailing address:
  • Phone: 401-396-7649
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberSAP173871
License Number StateRI
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCADC-200884
License Number StateRI
# 3
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCDP00711
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: