Provider Demographics
NPI:1497355911
Name:ROGERS, MATTHEW WAYNE (LMSW)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:WAYNE
Last Name:ROGERS
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16100 SPACE CENTER BLVD APT 211
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77062-6229
Mailing Address - Country:US
Mailing Address - Phone:281-235-3653
Mailing Address - Fax:
Practice Address - Street 1:6302 BROADWAY ST STE 235
Practice Address - Street 2:
Practice Address - City:PEARLAND
Practice Address - State:TX
Practice Address - Zip Code:77581-7828
Practice Address - Country:US
Practice Address - Phone:979-997-0051
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-26
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX61653104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker