Provider Demographics
NPI:1134306558
Name:RODGERS, KENNETH C (PHD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:C
Last Name:RODGERS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8160 HIGHLAND DR
Mailing Address - Street 2:# 102
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84093-6492
Mailing Address - Country:US
Mailing Address - Phone:801-943-3319
Mailing Address - Fax:801-733-7004
Practice Address - Street 1:8160 HIGHLAND DR
Practice Address - Street 2:# 102
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84093-6492
Practice Address - Country:US
Practice Address - Phone:801-943-3319
Practice Address - Fax:801-733-7004
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-28
Last Update Date:2008-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1114662501103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical