=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861013104
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOSE ANTONIO RODRIGUEZ CRSW
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/28/2020
-----------------------------------------------------
Last Update Date | 04/28/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 60 ROGERS ST UNIT 204
-----------------------------------------------------
City | MANCHESTER
-----------------------------------------------------
State | NH
-----------------------------------------------------
Zip | 03103-5098
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 603-309-7472
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1602 E MAIN ST APT 1
-----------------------------------------------------
City | CENTER CONWAY
-----------------------------------------------------
State | NH
-----------------------------------------------------
Zip | 03813-4117
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 978-761-3902
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | 0234
-----------------------------------------------------
License Number State | NH
-----------------------------------------------------