Provider Demographics
NPI:1679883730
Name:ROGERS, JOELLEN SALCE (PHD)
Entity Type:Individual
Prefix:
First Name:JOELLEN
Middle Name:SALCE
Last Name:ROGERS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:944 S PENINSULA DR APT 307
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32118-4784
Mailing Address - Country:US
Mailing Address - Phone:386-717-5722
Mailing Address - Fax:386-000-0000
Practice Address - Street 1:1219 DUNN AVE
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-2405
Practice Address - Country:US
Practice Address - Phone:386-255-4568
Practice Address - Fax:386-000-0000
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-07
Last Update Date:2021-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1000689103K00000X
FLSS0000114103T00000X
103TS0200X, 103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLJRONEOFFOURMedicaid