Provider Demographics
NPI:1265838890
Name:ROGERS, NICOLE (LISAC)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:ROGERS
Suffix:
Gender:F
Credentials:LISAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3710 W GREENWAY RD STE 104
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85053-3729
Mailing Address - Country:US
Mailing Address - Phone:602-466-2036
Mailing Address - Fax:
Practice Address - Street 1:3222 N 37TH ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85018-6304
Practice Address - Country:US
Practice Address - Phone:602-599-5554
Practice Address - Fax:602-599-5854
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-10
Last Update Date:2021-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171M00000XOther Service ProvidersCase Manager/Care Coordinator