Provider Demographics
NPI:1851437214
Name:ROGERS, GRACE W (PHD)
Entity Type:Individual
Prefix:DR
First Name:GRACE
Middle Name:W
Last Name:ROGERS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 617
Mailing Address - Street 2:
Mailing Address - City:NICASIO
Mailing Address - State:CA
Mailing Address - Zip Code:94946
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:250 BEL MARIN KEYS
Practice Address - Street 2:#C5
Practice Address - City:NOVATO
Practice Address - State:CA
Practice Address - Zip Code:94949-5708
Practice Address - Country:US
Practice Address - Phone:415-662-2388
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY14484103TC0700X
CAMFC27465106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOPL144840Medicare ID - Type Unspecified