Provider Demographics
NPI:1265683155
Name:RODGERS, CHARLES W (PHD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:W
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 1:822 N POINT CIR
Mailing Address - Street 2:
Mailing Address - City:RIVERTON
Mailing Address - State:WY
Mailing Address - Zip Code:82501-3346
Mailing Address - Country:US
Mailing Address - Phone:307-856-1333
Mailing Address - Fax:
Practice Address - Street 1:607 EAST WASHINGTON
Practice Address - Street 2:
Practice Address - City:RIVERTON
Practice Address - State:WY
Practice Address - Zip Code:82501
Practice Address - Country:US
Practice Address - Phone:307-856-1333
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-09
Last Update Date:2008-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY58103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY119106301Medicaid
WY119106301Medicaid
WY10451Medicare PIN