Provider Demographics
NPI:1922172683
Name:ROGERS, GARY L (PHD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:L
Last Name:ROGERS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34 OAK ST
Mailing Address - Street 2:
Mailing Address - City:EAST ELLIJAY
Mailing Address - State:GA
Mailing Address - Zip Code:30540-8151
Mailing Address - Country:US
Mailing Address - Phone:706-636-5679
Mailing Address - Fax:706-636-5680
Practice Address - Street 1:34 OAK ST
Practice Address - Street 2:
Practice Address - City:EAST ELLIJAY
Practice Address - State:GA
Practice Address - Zip Code:30540-8151
Practice Address - Country:US
Practice Address - Phone:706-636-5679
Practice Address - Fax:706-636-5680
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1824103TC0700X, 103TF0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Not Answered103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00626315EMedicaid
GA68BBCQRMedicare ID - Type Unspecified
GA00626315EMedicaid