Provider Demographics
NPI:1558029926
Name:RODGERS, SHANO PALOVICH (MFT)
Entity Type:Individual
Prefix:DR
First Name:SHANO
Middle Name:PALOVICH
Last Name:RODGERS
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1464 MADERA RD # 159
Mailing Address - Street 2:
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93065-3077
Mailing Address - Country:US
Mailing Address - Phone:310-433-5819
Mailing Address - Fax:
Practice Address - Street 1:1955 MORLEY ST
Practice Address - Street 2:
Practice Address - City:SIMI VALLEY
Practice Address - State:CA
Practice Address - Zip Code:93065-3528
Practice Address - Country:US
Practice Address - Phone:310-433-5819
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-02
Last Update Date:2021-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA41080106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist