Basic Information
| Provider Information | |||||||||
| NPI: | 1699976738 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RODRIGUEZ | ||||||||
| FirstName: | MAYRA | ||||||||
| MiddleName: | BERENISE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2057 HIGH ST | ||||||||
| Address2: | |||||||||
| City: | OAKLAND | ||||||||
| State: | CA | ||||||||
| PostalCode: | 946014619 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5105323361 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1501 FRUITVALE AVE | ||||||||
| Address2: | |||||||||
| City: | OAKLAND | ||||||||
| State: | CA | ||||||||
| PostalCode: | 946012322 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5105356200 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/29/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.