Provider Demographics
NPI:1619370004
Name:RODRIGUEZ, PHYLLIS LOUISE
Entity type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:LOUISE
Last Name:RODRIGUEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3420 WINTER WAY
Mailing Address - Street 2:
Mailing Address - City:MADERA
Mailing Address - State:CA
Mailing Address - Zip Code:93637-5956
Mailing Address - Country:US
Mailing Address - Phone:559-275-3555
Mailing Address - Fax:
Practice Address - Street 1:496 S BARTON AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93702-2985
Practice Address - Country:US
Practice Address - Phone:559-374-3990
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-30
Last Update Date:2023-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 35583167G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes167G00000XNursing Service ProvidersLicensed Psychiatric Technician