Provider Demographics
NPI:1114635125
Name:ROGERS, DESTANI LACOLE (LCSWA)
Entity Type:Individual
Prefix:
First Name:DESTANI
Middle Name:LACOLE
Last Name:ROGERS
Suffix:
Gender:F
Credentials:LCSWA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1260 MELON COLONY AVE SW
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28027-0265
Mailing Address - Country:US
Mailing Address - Phone:704-960-3942
Mailing Address - Fax:
Practice Address - Street 1:5700 EXECUTIVE CENTER DR STE 110
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28212-8833
Practice Address - Country:US
Practice Address - Phone:866-272-7826
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-08
Last Update Date:2022-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0184121041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical