=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750890661
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DENNIS ESTRADA RODRIGO
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/22/2017
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1149 INDEPENDENCE TRAIL APT K
-----------------------------------------------------
City | HOMESTEAD
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33034
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-459-6422
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1149 INDEPENDENCE TRL APT K
-----------------------------------------------------
City | HOMESTEAD
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33034-2610
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-459-6422
-----------------------------------------------------
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 | 18-69692
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------