Provider Demographics
NPI:1134006695
Name:STALLARD, RODRIGO
Entity type:Individual
Prefix:
First Name:RODRIGO
Middle Name:
Last Name:STALLARD
Suffix:
Gender:X
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4734 217TH ST
Mailing Address - Street 2:APT 3C
Mailing Address - City:BAYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11361
Mailing Address - Country:US
Mailing Address - Phone:305-904-9841
Mailing Address - Fax:
Practice Address - Street 1:4734 217TH ST APT 3C
Practice Address - Street 2:
Practice Address - City:BAYSIDE
Practice Address - State:NY
Practice Address - Zip Code:11361-3570
Practice Address - Country:US
Practice Address - Phone:305-904-9841
Practice Address - Fax:305-904-9841
Is Sole Proprietor?:No
Enumeration Date:2025-08-18
Last Update Date:2025-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP130414103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst