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General NPI Number Information
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NPI Number | 1699216580
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Entity Type | Individual
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Provider Name | JOSE RODRIGUEZ LCSW
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Gender | Male
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Dates
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Enumeration Date | 03/13/2017
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Last Update Date | 03/13/2017
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Provider Practice Location Address
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Address Line | 1478 KENWOOD DR SUITE 1
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City | MENASHA
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State | WI
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Zip | 54952-1161
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Country | US
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Telephone | 920-886-9319
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Fax | 920-886-9357
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Provider Business Mailing Address
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Address Line | 410 W 10TH AVE P. O. BOX 2145
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City | OSHKOSH
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State | WI
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Zip | 54903-2145
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Country | US
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Telephone | 920-886-9319
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Fax | 920-886-9357
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | 12601
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License Number State | WI
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Taxonomy #2
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 278
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License Number State | WI
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Taxonomy #3
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 1883
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License Number State | WI
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