=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659989754
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ELIZABETH J RODRIGUEZ
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/15/2020
-----------------------------------------------------
Last Update Date | 07/15/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4209 N 18TH EAST ST
-----------------------------------------------------
City | MOUNTAIN HOME
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83647-5899
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-599-0944
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4209 N 18TH E
-----------------------------------------------------
City | MOUNTAIN HOME
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83647-5899
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-599-0944
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106S00000X
-----------------------------------------------------
Taxonomy Name | Behavior Technician
-----------------------------------------------------
License Number | A0003962
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------