Provider Demographics
NPI:1255647863
Name:RODRIGUEZ, LYDIA MERCEDES
Entity type:Individual
Prefix:
First Name:LYDIA
Middle Name:MERCEDES
Last Name:RODRIGUEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7321
Mailing Address - Street 2:
Mailing Address - City:PONCE
Mailing Address - State:PR
Mailing Address - Zip Code:00732-7321
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:CARRETERA #14
Practice Address - Street 2:AVE. TITO CASTRO
Practice Address - City:PONCE
Practice Address - State:PR
Practice Address - Zip Code:00732
Practice Address - Country:US
Practice Address - Phone:787-840-6630
Practice Address - Fax:787-844-4130
Is Sole Proprietor?:No
Enumeration Date:2010-08-20
Last Update Date:2010-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR396101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR279728OtherSBSTANCE ABUSE TREATMENT