Provider Demographics
NPI:1831672526
Name:ROGERS, LATRELLE (BCBA)
Entity Type:Individual
Prefix:
First Name:LATRELLE
Middle Name:
Last Name:ROGERS
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17206 LANCASTER HWY STE 501
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28277-2004
Mailing Address - Country:US
Mailing Address - Phone:540-235-2474
Mailing Address - Fax:
Practice Address - Street 1:17206 LANCASTER HWY STE 501
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28277-2004
Practice Address - Country:US
Practice Address - Phone:540-235-2474
Practice Address - Fax:980-939-1030
Is Sole Proprietor?:No
Enumeration Date:2018-09-10
Last Update Date:2018-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1-18-30190103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1-17-30190OtherBCBA