=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982196556
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MR. DAVID RODRIGUEZ
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/30/2018
-----------------------------------------------------
Last Update Date | 05/30/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 728 BAYBERRY DR
-----------------------------------------------------
City | BARTLETT
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60103-4444
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-656-9066
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 728 BAYBERRY DR
-----------------------------------------------------
City | BARTLETT
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60103-4444
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-656-9066
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101Y00000X
-----------------------------------------------------
Taxonomy Name | Counselor
-----------------------------------------------------
License Number | R362-1608-5326
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------