Provider Demographics
NPI:1760499578
Name:ROGERS, THERESA NELSON (AUD CCC-A)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:NELSON
Last Name:ROGERS
Suffix:
Gender:F
Credentials:AUD CCC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:750 S BENNETT ST
Mailing Address - Street 2:
Mailing Address - City:SOUTHERN PINES
Mailing Address - State:NC
Mailing Address - Zip Code:28387-5922
Mailing Address - Country:US
Mailing Address - Phone:910-693-3777
Mailing Address - Fax:910-692-2848
Practice Address - Street 1:750 S BENNETT ST
Practice Address - Street 2:
Practice Address - City:SOUTHERN PINES
Practice Address - State:NC
Practice Address - Zip Code:28387
Practice Address - Country:US
Practice Address - Phone:910-693-3777
Practice Address - Fax:910-692-2848
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-02
Last Update Date:2018-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC826237600000X
NC3566231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
No237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC269N9505AMedicare PIN