Provider Demographics
NPI:1578521613
Name:ROGERS, EDWIN SAMUEL (PHD, ABPP)
Entity Type:Individual
Prefix:
First Name:EDWIN
Middle Name:SAMUEL
Last Name:ROGERS
Suffix:
Gender:M
Credentials:PHD, ABPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1924 ALCOA HWY
Mailing Address - Street 2:U-67
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37920-1511
Mailing Address - Country:US
Mailing Address - Phone:865-544-9352
Mailing Address - Fax:865-544-9314
Practice Address - Street 1:1924 ALCOA HWY
Practice Address - Street 2:U-115
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37920-1511
Practice Address - Country:US
Practice Address - Phone:865-544-9351
Practice Address - Fax:865-544-9314
Is Sole Proprietor?:No
Enumeration Date:2006-05-01
Last Update Date:2012-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNP740103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNTN01H8OtherJOHN DEERE
TN3373352OtherUFP MEDICAID GRP
680011669OtherRAILROAD MEDICARE
TN3373352OtherUFP MEDICARE GRP
TN1689631137OtherGROUP NPI
TN3680230OtherAETNA
TN1689631137OtherGROUP NPI
680011669OtherRAILROAD MEDICARE
TN3373352OtherUFP MEDICAID GRP