Provider Demographics
NPI:1376034942
Name:ROGERS, AJA A (THERAPUTIC MENTOR)
Entity Type:Individual
Prefix:MISS
First Name:AJA
Middle Name:A
Last Name:ROGERS
Suffix:
Gender:F
Credentials:THERAPUTIC MENTOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:695 TRUMAN HWY STE 202
Mailing Address - Street 2:
Mailing Address - City:HYDE PARK
Mailing Address - State:MA
Mailing Address - Zip Code:02136-3552
Mailing Address - Country:US
Mailing Address - Phone:888-763-7272
Mailing Address - Fax:
Practice Address - Street 1:695 TRUMAN HWY STE 202
Practice Address - Street 2:
Practice Address - City:HYDE PARK
Practice Address - State:MA
Practice Address - Zip Code:02136-3552
Practice Address - Country:US
Practice Address - Phone:888-763-7272
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-19
Last Update Date:2018-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA$$$$$$$$$Medicaid