Provider Demographics
NPI:1033147509
Name:RODGERS, IRENE MARIE (LCSW)
Entity Type:Individual
Prefix:MS
First Name:IRENE
Middle Name:MARIE
Last Name:RODGERS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23 JACKSON AVE
Mailing Address - Street 2:
Mailing Address - City:BAYVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11709-1333
Mailing Address - Country:US
Mailing Address - Phone:516-628-3065
Mailing Address - Fax:
Practice Address - Street 1:506 STEWART AVE
Practice Address - Street 2:
Practice Address - City:GARDEN CITY
Practice Address - State:NY
Practice Address - Zip Code:11530-4706
Practice Address - Country:US
Practice Address - Phone:516-739-7733
Practice Address - Fax:516-739-3923
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0725391041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYNH2111Medicare ID - Type UnspecifiedLCSW