Provider Demographics
NPI:1487421616
Name:RODRIGUEZ FERNANDEZ, KEVIS
Entity type:Individual
Prefix:
First Name:KEVIS
Middle Name:
Last Name:RODRIGUEZ FERNANDEZ
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 1:8300 NW 53RD ST STE 350
Mailing Address - Street 2:
Mailing Address - City:DORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33166-7712
Mailing Address - Country:US
Mailing Address - Phone:305-342-7643
Mailing Address - Fax:
Practice Address - Street 1:8300 NW 53RD ST STE 350
Practice Address - Street 2:
Practice Address - City:DORAL
Practice Address - State:FL
Practice Address - Zip Code:33166-7712
Practice Address - Country:US
Practice Address - Phone:305-342-7643
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-07
Last Update Date:2023-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty