Provider Demographics
NPI:1639620412
Name:RODGERS, DIAMOND
Entity Type:Individual
Prefix:
First Name:DIAMOND
Middle Name:
Last Name:RODGERS
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 1:4360 TERRACE HILL RD APT 12-204
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89103-4585
Mailing Address - Country:US
Mailing Address - Phone:702-236-4209
Mailing Address - Fax:
Practice Address - Street 1:5915 S RAINBOW BLVD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89118-2557
Practice Address - Country:US
Practice Address - Phone:702-209-0370
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-17
Last Update Date:2020-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV101YM0800X
NV3121106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health