Provider Demographics
NPI:1467424895
Name:ROGERS, SAMUEL JR (PHD)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:
Last Name:ROGERS
Suffix:JR
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2727 ELECTRIC RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24018-3547
Mailing Address - Country:US
Mailing Address - Phone:540-772-5153
Mailing Address - Fax:540-772-5157
Practice Address - Street 1:2840 ELECTRIC RD STE 200
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24018-3551
Practice Address - Country:US
Practice Address - Phone:540-772-5153
Practice Address - Fax:540-772-5158
Is Sole Proprietor?:No
Enumeration Date:2006-02-01
Last Update Date:2019-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810001141103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010279569Medicaid
VA00W685L11Medicare ID - Type UnspecifiedRICHMOND MEDICARE