Provider Demographics
NPI:1508916503
Name:ROGERS, JUDI TAYLOR (LCSW)
Entity Type:Individual
Prefix:
First Name:JUDI
Middle Name:TAYLOR
Last Name:ROGERS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:90 SAN JUAN DR APT B104
Mailing Address - Street 2:
Mailing Address - City:PALM COAST
Mailing Address - State:FL
Mailing Address - Zip Code:32137-2368
Mailing Address - Country:US
Mailing Address - Phone:770-331-9344
Mailing Address - Fax:386-283-4170
Practice Address - Street 1:100 MARINERS DR STE D
Practice Address - Street 2:
Practice Address - City:KINGSLAND
Practice Address - State:GA
Practice Address - Zip Code:31548-6667
Practice Address - Country:US
Practice Address - Phone:770-656-4401
Practice Address - Fax:386-283-4170
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-11
Last Update Date:2020-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0025161041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00851023BMedicaid
GA556442Medicare UPIN
GA80BBFGDMedicare ID - Type Unspecified