Provider Demographics
NPI:1942078381
Name:RODGERS, CHARVASE R
Entity Type:Individual
Prefix:
First Name:CHARVASE
Middle Name:R
Last Name:RODGERS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20439 STRATHERN ST
Mailing Address - Street 2:
Mailing Address - City:WINNETKA
Mailing Address - State:CA
Mailing Address - Zip Code:91306-2229
Mailing Address - Country:US
Mailing Address - Phone:480-326-4262
Mailing Address - Fax:
Practice Address - Street 1:20439 STRATHERN ST
Practice Address - Street 2:
Practice Address - City:WINNETKA
Practice Address - State:CA
Practice Address - Zip Code:91306-2229
Practice Address - Country:US
Practice Address - Phone:480-326-4262
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-14
Last Update Date:2023-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician