Healthcare Provider Details

I. General information

NPI: 1598591158
Provider Name (Legal Business Name): MILAGROS GRACIELA RODRIGUEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/10/2024
Last Update Date: 06/10/2026
Certification Date: 06/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

491 CARLISLE DR STE A
HERNDON VA
20170-4895
US

IV. Provider business mailing address

491 CARLISLE DR STE A
HERNDON VA
20170-4895
US

V. Phone/Fax

Practice location:
  • Phone: 770-869-9601
  • Fax:
Mailing address:
  • Phone: 770-869-9601
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number0019019809
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: