Provider Demographics
NPI:1922596998
Name:ROGERS, KENNETH CHARLES (EDD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:CHARLES
Last Name:ROGERS
Suffix:
Gender:M
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:294 BLUE HILL AVE
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:MA
Mailing Address - Zip Code:02186-1015
Mailing Address - Country:US
Mailing Address - Phone:617-291-6927
Mailing Address - Fax:
Practice Address - Street 1:425 HARVARD ST
Practice Address - Street 2:
Practice Address - City:DORCHESTER
Practice Address - State:MA
Practice Address - Zip Code:02124-2737
Practice Address - Country:US
Practice Address - Phone:617-740-0109
Practice Address - Fax:617-740-0110
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-25
Last Update Date:2018-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2818103TH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth ServiceGroup - Single Specialty