Provider Demographics
NPI:1730806522
Name:RODRIGUEZ, ANA (LAC)
Entity type:Individual
Prefix:
First Name:ANA
Middle Name:
Last Name:RODRIGUEZ
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:ANA
Other - Middle Name:
Other - Last Name:RODRIGUEZ ORTIZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LAC
Mailing Address - Street 1:2809 FOREST HOME RD
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72401-5320
Mailing Address - Country:US
Mailing Address - Phone:866-972-1268
Mailing Address - Fax:
Practice Address - Street 1:1108 POPLAR PL
Practice Address - Street 2:
Practice Address - City:ROGERS
Practice Address - State:AR
Practice Address - Zip Code:72756-4249
Practice Address - Country:US
Practice Address - Phone:479-372-6464
Practice Address - Fax:479-372-6460
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-24
Last Update Date:2023-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA2208012101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR291278795Medicaid