Provider Demographics
NPI:1780416818
Name:DAVIS-RODRIGUEZ, NELLY JOHANA
Entity type:Individual
Prefix:
First Name:NELLY
Middle Name:JOHANA
Last Name:DAVIS-RODRIGUEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:NELLY
Other - Middle Name:JOHANA
Other - Last Name:RODRIGUEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 346
Mailing Address - Street 2:
Mailing Address - City:BROWNVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13615-0346
Mailing Address - Country:US
Mailing Address - Phone:973-568-7647
Mailing Address - Fax:
Practice Address - Street 1:4 FULLER ST
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA BAY
Practice Address - State:NY
Practice Address - Zip Code:13607-1391
Practice Address - Country:US
Practice Address - Phone:315-486-0510
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-16
Last Update Date:2024-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY124319-01104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker