Healthcare Provider Details

I. General information

NPI: 1710802046
Provider Name (Legal Business Name): ROSE RODRIGUEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/13/2026
Last Update Date: 08/13/2026
Certification Date: 08/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4841 MERLOT AVE UNIT 420
GRAPEVINE TX
76051-7382
US

IV. Provider business mailing address

1510 BRIAR ST
PORTLAND TX
78374-2206
US

V. Phone/Fax

Practice location:
  • Phone: 817-809-8399
  • Fax:
Mailing address:
  • Phone: 361-816-5236
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number102982
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: