Provider Demographics
NPI:1902560261
Name:RHODEN, ASTLEY
Entity Type:Individual
Prefix:
First Name:ASTLEY
Middle Name:
Last Name:RHODEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2501 BRISTOL DR STE 12A
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33409-6463
Mailing Address - Country:US
Mailing Address - Phone:754-368-4320
Mailing Address - Fax:
Practice Address - Street 1:2501 BRISTOL DR STE 12A
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33409-6463
Practice Address - Country:US
Practice Address - Phone:754-368-4320
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-23
Last Update Date:2021-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL105087100Medicaid