=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467845909
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHRISTINA RODRIGUEZ
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/09/2015
-----------------------------------------------------
Last Update Date | 05/29/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3053 HARRISON AVE STE 203
-----------------------------------------------------
City | SOUTH LAKE TAHOE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 96150-7950
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 559-656-9029
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3053 HARRISON AVE STE 203
-----------------------------------------------------
City | SOUTH LAKE TAHOE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 96150-7950
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 559-656-9029
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | 106710
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------