Provider Demographics
NPI:1093464752
Name:ROGERS, NICOLE (LAC)
Entity Type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:
Last Name:ROGERS
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 E GUADALUPE RD APT 11206
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85234-4692
Mailing Address - Country:US
Mailing Address - Phone:480-343-3763
Mailing Address - Fax:
Practice Address - Street 1:29858 N TATUM BLVD # 100
Practice Address - Street 2:
Practice Address - City:CAVE CREEK
Practice Address - State:AZ
Practice Address - Zip Code:85331-5865
Practice Address - Country:US
Practice Address - Phone:480-923-6267
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-21
Last Update Date:2022-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ19645101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ81261553Medicaid