Provider Demographics
NPI:1831642990
Name:ROGERS, DIANE H
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:H
Last Name:ROGERS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1010 MASSACHUSETTS AVE FL 6
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-2600
Mailing Address - Country:US
Mailing Address - Phone:617-534-3134
Mailing Address - Fax:857-288-2315
Practice Address - Street 1:112 SOUTHAMPTON ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118-2711
Practice Address - Country:US
Practice Address - Phone:617-534-3167
Practice Address - Fax:857-288-2240
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-25
Last Update Date:2019-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2253431041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical