=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679212476
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DENISE RODRIGUEZ, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/31/2022
-----------------------------------------------------
Last Update Date | 01/02/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2885 N BROOKBURY XING
-----------------------------------------------------
City | FAYETTEVILLE
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72703-4377
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-466-8986
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2885 N BROOKBURY XING
-----------------------------------------------------
City | FAYETTEVILLE
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72703-4377
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-466-8986
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DENISE C RODRIGUEZ
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 479-466-8986
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------