Provider Demographics
NPI:1851574768
Name:RODGERS, CARLY J (PHD)
Entity Type:Individual
Prefix:DR
First Name:CARLY
Middle Name:J
Last Name:RODGERS
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 1:205 OCEAN AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04103-5712
Mailing Address - Country:US
Mailing Address - Phone:207-554-7906
Mailing Address - Fax:207-773-5512
Practice Address - Street 1:205 OCEAN AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04103-5712
Practice Address - Country:US
Practice Address - Phone:207-554-7906
Practice Address - Fax:207-773-5512
Is Sole Proprietor?:No
Enumeration Date:2007-12-13
Last Update Date:2020-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPS1555103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME103850000OtherMAINE CARE