Provider Demographics
NPI:1811582182
Name:ROGERS, LARRY LEE
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:LEE
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 1:685 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:PATERSON
Mailing Address - State:NJ
Mailing Address - Zip Code:07504-1035
Mailing Address - Country:US
Mailing Address - Phone:973-204-5902
Mailing Address - Fax:
Practice Address - Street 1:777 BLOOMFIELD AVE
Practice Address - Street 2:
Practice Address - City:CLIFTON
Practice Address - State:NJ
Practice Address - Zip Code:07012-1242
Practice Address - Country:US
Practice Address - Phone:973-594-0125
Practice Address - Fax:973-594-0536
Is Sole Proprietor?:No
Enumeration Date:2021-03-08
Last Update Date:2021-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC008499001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical