MEDICARE: MARJORIE DIAZ RODRIGUEZ LCSW, BCBA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	149.011093	IL
2	103K00000X	Behavior Analyst	1-19-37412	IL

General Provider Information

NPI Number	:	1578879433
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARJORIE DIAZ RODRIGUEZ LCSW, BCBA

Provider Business Mailing Address
First Line	:	1261 E PALATINE RD
Second Line	:
City	:	PALATINE
State	:	IL
Zip	:	60074-5777
Country	:	US
Telephone Number	:	847-772-2029
Fax Number	:

Provider Business Practice Location Address
First Line	:	3417 N KENNICOTT AVE STE A
Second Line	:
City	:	ARLINGTON HEIGHTS
State	:	IL
Zip	:	60004-7824
Country	:	US
Telephone Number	:	224-210-6694
Fax Number	:	224-836-5174

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/28/2010
Last Update Date	:	09/23/2019

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