=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043823446
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ROSA SARAITH RODRIGUEZ EVANGELISTA RADT-I
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/25/2020
-----------------------------------------------------
Last Update Date | 12/07/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2100 NAPA VALLEJO HWY BLDG M1M2
-----------------------------------------------------
City | NAPA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94558-6234
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-255-8001
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1900 MAXWELL CANYON RD
-----------------------------------------------------
City | SAINT HELENA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94574-9638
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-880-6397
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251K00000X
-----------------------------------------------------
Taxonomy Name | Public Health or Welfare Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | R1403560820
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------