Provider Demographics
NPI:1538221569
Name:RODRIGUEZ, DAVID A (PHD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:A
Last Name:RODRIGUEZ
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28 FOREST LN
Mailing Address - Street 2:
Mailing Address - City:BREWSTER
Mailing Address - State:NY
Mailing Address - Zip Code:10509-3014
Mailing Address - Country:US
Mailing Address - Phone:845-278-6591
Mailing Address - Fax:
Practice Address - Street 1:3512 QUENTIN RD STE 110
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11234-4245
Practice Address - Country:US
Practice Address - Phone:800-275-3243
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-15
Last Update Date:2021-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY021988103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1285628552OtherAGENCY NPI
NY00355940Medicaid
NY1285628552OtherAGENCY NPI