=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568682631
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MYRNA IRIS RODRIGUEZ PH.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/30/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8129 CALLE CONCORDIA CONDO. CONCORDIA SUITE502
-----------------------------------------------------
City | PONCE
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00717-1548
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-844-0125
-----------------------------------------------------
Fax | 787-844-9019
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5009 PASEO CONSTANCIA HACIENDAS DEL MONTE
-----------------------------------------------------
City | COTO LAUREL
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00780-2372
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-848-1002
-----------------------------------------------------
Fax | 787-844-9019
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 439
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------