Provider Demographics
NPI:1396362349
Name:RODGERS, HAILEY (CPRS)
Entity Type:Individual
Prefix:
First Name:HAILEY
Middle Name:
Last Name:RODGERS
Suffix:
Gender:F
Credentials:CPRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:504 BEECHWOOD DR
Mailing Address - Street 2:
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37663-2455
Mailing Address - Country:US
Mailing Address - Phone:423-767-0830
Mailing Address - Fax:
Practice Address - Street 1:2408 SUSANNAH ST STE 1
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37601-1765
Practice Address - Country:US
Practice Address - Phone:423-434-6677
Practice Address - Fax:423-461-0000
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-25
Last Update Date:2020-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1234101Y00000X, 175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor