Provider Demographics
NPI:1275192478
Name:ROGERS, DWAYNE CALVIN
Entity Type:Individual
Prefix:
First Name:DWAYNE
Middle Name:CALVIN
Last Name:ROGERS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3530 E FLAMINGO RD STE 100
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89121-5091
Mailing Address - Country:US
Mailing Address - Phone:702-856-6785
Mailing Address - Fax:702-816-3403
Practice Address - Street 1:3530 E FLAMINGO RD STE 100
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89121-5091
Practice Address - Country:US
Practice Address - Phone:702-816-3400
Practice Address - Fax:702-816-3403
Is Sole Proprietor?:No
Enumeration Date:2019-06-11
Last Update Date:2020-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVMI1174101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1275192478Medicaid
NVMI1174OtherMARRIAGE AND FAMILY INTERN NUMBER