Basic Information
Provider Information
NPI: 1003141607
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: RODRIGUEZ
FirstName: OCTAVIANA
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 6500 S. MOONEY BLVD.
Address2: SUITE B
City: VISALIA
State: CA
PostalCode: 93277
CountryCode: US
TelephoneNumber: 5596851200
FaxNumber:  
Practice Location
Address1: 6500 S. MOONEY BLVD.
Address2: SUITE B
City: VISALIA
State: CA
PostalCode: 93277
CountryCode: US
TelephoneNumber: 5596851200
FaxNumber:  
Other Information
ProviderEnumerationDate: 10/15/2009
LastUpdateDate: 10/15/2009
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
101Y00000X  Y Behavioral Health & Social Service ProvidersCounselor 

No ID Information.


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