Provider Demographics
NPI:1114316601
Name:ROGERS, MIYA (LPC)
Entity Type:Individual
Prefix:
First Name:MIYA
Middle Name:
Last Name:ROGERS
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4824 SMALLWOOD RD APT 187
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29223-3238
Mailing Address - Country:US
Mailing Address - Phone:414-499-7193
Mailing Address - Fax:
Practice Address - Street 1:2715 COLONIAL DR STE 100A
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-6818
Practice Address - Country:US
Practice Address - Phone:803-898-4777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-21
Last Update Date:2018-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X, 101YM0800X
WI2267-226101YP2500X
SC6964101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
3335OtherMEDICARE
SC421504Medicaid