Provider Demographics
NPI:1255691077
Name:ROGERS, SHANNON (MFT)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:ROGERS
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:445 BELLEVUE AVE
Mailing Address - Street 2:SUITE 201B
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94610-4923
Mailing Address - Country:US
Mailing Address - Phone:510-463-4054
Mailing Address - Fax:
Practice Address - Street 1:445 BELLEVUE AVE
Practice Address - Street 2:SUITE 201B
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94610-4923
Practice Address - Country:US
Practice Address - Phone:510-463-4054
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-26
Last Update Date:2016-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist