Healthcare Provider Details

I. General information

NPI: 1194206151
Provider Name (Legal Business Name): GLODELIZ RODRIGUEZ LPC, CSAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/27/2018
Last Update Date: 08/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

247 MCLAWS CIR
WILLIAMSBURG VA
23185-5660
US

IV. Provider business mailing address

4692 NOLAND BLVD
WILLIAMSBURG VA
23188-7587
US

V. Phone/Fax

Practice location:
  • Phone: 757-253-0111
  • Fax: 757-253-2884
Mailing address:
  • Phone: 252-341-8351
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number0710102911
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: