Provider Demographics
NPI:1477314193
Name:ROGERS, KENEDY ETTA
Entity Type:Individual
Prefix:
First Name:KENEDY
Middle Name:ETTA
Last Name:ROGERS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:366 GREEN MOUNTAIN DR
Mailing Address - Street 2:
Mailing Address - City:NACOGDOCHES
Mailing Address - State:TX
Mailing Address - Zip Code:75964-2401
Mailing Address - Country:US
Mailing Address - Phone:936-635-1016
Mailing Address - Fax:
Practice Address - Street 1:366 GREEN MOUNTAIN DR
Practice Address - Street 2:
Practice Address - City:NACOGDOCHES
Practice Address - State:TX
Practice Address - Zip Code:75964-2401
Practice Address - Country:US
Practice Address - Phone:936-635-1016
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-19
Last Update Date:2024-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX436342355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant