MEDICARE: JUAN RODRIGUEZ LCSW

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	127365	CA

General Provider Information

NPI Number	:	1689486110
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JUAN RODRIGUEZ LCSW

Provider Business Mailing Address
First Line	:	PO BOX 18033
Second Line	:
City	:	SOUTH LAKE TAHOE
State	:	CA
Zip	:	96151-8033
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	PO BOX 18033
Second Line	:
City	:	SOUTH LAKE TAHOE
State	:	CA
Zip	:	96151-8033
Country	:	US
Telephone Number	:	530-601-6318
Fax Number	:

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

Provider Enumeration Date	:	01/22/2025
Last Update Date	:	01/22/2025

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