Provider Demographics
NPI:1124539978
Name:ROGERS, EVELYN VIRGINIA
Entity Type:Individual
Prefix:
First Name:EVELYN
Middle Name:VIRGINIA
Last Name:ROGERS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12647 OLIVE BLVD STE 600
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-6346
Mailing Address - Country:US
Mailing Address - Phone:800-325-3982
Mailing Address - Fax:888-685-9880
Practice Address - Street 1:12647 OLIVE BLVD STE 600
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-6346
Practice Address - Country:US
Practice Address - Phone:800-325-3982
Practice Address - Fax:888-685-9880
Is Sole Proprietor?:No
Enumeration Date:2017-10-19
Last Update Date:2017-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0897101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)