Provider Demographics
NPI:1962500355
Name:RODGERS, KATHLEEN (LCSW)
Entity Type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:
Last Name:RODGERS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 HARTWOOD RD
Mailing Address - Street 2:
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850-9696
Mailing Address - Country:US
Mailing Address - Phone:607-277-0438
Mailing Address - Fax:607-277-0438
Practice Address - Street 1:40 HARTWOOD RD
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-9696
Practice Address - Country:US
Practice Address - Phone:607-277-0438
Practice Address - Fax:607-277-0438
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2014-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR039333-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY133021OtherVALUE OPTIONS
NYBB8967OtherMEDICARE PCAN