Healthcare Provider Details

I. General information

NPI: 1720594757
Provider Name (Legal Business Name): RICARDO ISRAEL RODRIGUEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/28/2017
Last Update Date: 12/15/2025
Certification Date: 12/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

151 S UNIVERSITY AVE
PROVO UT
84601-4427
US

IV. Provider business mailing address

1198 S 1220 W
PROVO UT
84601-5470
US

V. Phone/Fax

Practice location:
  • Phone: 801-851-7127
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number12366411-3502
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: