Provider Demographics
NPI:1326598673
Name:ROGERS, DUSTIN (BA)
Entity Type:Individual
Prefix:
First Name:DUSTIN
Middle Name:
Last Name:ROGERS
Suffix:
Gender:M
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1524 EVERETT ST
Mailing Address - Street 2:
Mailing Address - City:CALDWELL
Mailing Address - State:ID
Mailing Address - Zip Code:83605-4245
Mailing Address - Country:US
Mailing Address - Phone:208-936-9684
Mailing Address - Fax:
Practice Address - Street 1:3402 FRANKLIN RD
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83605-6932
Practice Address - Country:US
Practice Address - Phone:208-459-0092
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-11
Last Update Date:2016-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician