Provider Demographics
NPI:1760945679
Name:ROGERS, KAYLA (RADT)
Entity Type:Individual
Prefix:
First Name:KAYLA
Middle Name:
Last Name:ROGERS
Suffix:
Gender:F
Credentials:RADT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:402 N WEITZEL ST APT 204
Mailing Address - Street 2:
Mailing Address - City:OCEANSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92054-2616
Mailing Address - Country:US
Mailing Address - Phone:619-357-9535
Mailing Address - Fax:
Practice Address - Street 1:1100 SPORTFISHER DR
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:CA
Practice Address - Zip Code:92054-2550
Practice Address - Country:US
Practice Address - Phone:760-439-6702
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-08
Last Update Date:2019-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1343100419101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAD4082463Medicaid