Basic Information
| Provider Information | |||||||||
| NPI: | 1417340712 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RODRIGUEZ | ||||||||
| FirstName: | STEVEN | ||||||||
| MiddleName: | JR | ||||||||
| NamePrefix: | MR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 77 JARDINE ST | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 011071750 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4133743307 | ||||||||
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| Practice Location | |||||||||
| Address1: | 417 LIBERTY ST | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 011043736 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4137470705 | ||||||||
| FaxNumber: | 4137327075 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/11/2015 | ||||||||
| LastUpdateDate: | 04/16/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/16/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | N | Behavioral Health & Social Service Providers | Behavioral Analyst | 103K00000X | 1391 | MA | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
ID Information
| ID | Type | State | Issuer | Description | 110027780B | 05 | MA | MEDICAID |