Healthcare Provider Details

I. General information

NPI: 1063356152
Provider Name (Legal Business Name): TERA MARIE MAE RODRIGUEZ IPHM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/17/2026
Last Update Date: 05/02/2026
Certification Date: 05/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 12TH ST LOT 9C
KIEL WI
53042-4830
US

IV. Provider business mailing address

620 12TH ST LOT 9C
KIEL WI
53042-4830
US

V. Phone/Fax

Practice location:
  • Phone: 920-571-7269
  • Fax:
Mailing address:
  • Phone: 920-571-7269
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-24-377640
License Number StateWI
# 4
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number StateWI
# 5
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: