Provider Demographics
NPI:1396002234
Name:ROGERS, NICOLE M (MS/SLP)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:M
Last Name:ROGERS
Suffix:
Gender:F
Credentials:MS/SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:902 CHATHAM CT
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22901-1741
Mailing Address - Country:US
Mailing Address - Phone:141-449-4592
Mailing Address - Fax:434-979-8536
Practice Address - Street 1:902 CHATHAM CT
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22901-1741
Practice Address - Country:US
Practice Address - Phone:141-449-4592
Practice Address - Fax:434-979-8536
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-17
Last Update Date:2012-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2202006334235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA4980671Medicaid