Provider Demographics
NPI:1801202148
Name:ROGERS, RODNEY
Entity Type:Individual
Prefix:
First Name:RODNEY
Middle Name:
Last Name:ROGERS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:168 PINECREST AVE
Mailing Address - Street 2:
Mailing Address - City:PLANTERSVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38862-5006
Mailing Address - Country:US
Mailing Address - Phone:662-255-2873
Mailing Address - Fax:
Practice Address - Street 1:4579 S EASON BLVD
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38801-6539
Practice Address - Country:US
Practice Address - Phone:662-377-2872
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-08
Last Update Date:2014-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MST0302106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist