Provider Demographics
NPI:1437971702
Name:RODRIGUEZ, IAN RODRIGUEZ JESUS
Entity type:Individual
Prefix:
First Name:IAN RODRIGUEZ
Middle Name:JESUS
Last Name:RODRIGUEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12330 PELLICANO DR.
Mailing Address - Street 2:SUITE B
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79936-4659
Mailing Address - Country:US
Mailing Address - Phone:915-613-5255
Mailing Address - Fax:
Practice Address - Street 1:12330 PELLICANO DR.
Practice Address - Street 2:SUITE B
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79936-4659
Practice Address - Country:US
Practice Address - Phone:915-613-5255
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-29
Last Update Date:2025-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXRBT-24-387448106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty