Provider Demographics
NPI:1205088770
Name:ROGERS, DONETTA R (SLP)
Entity type:Individual
Prefix:MRS
First Name:DONETTA
Middle Name:R
Last Name:ROGERS
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1902 W 2ND PL
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72801-4612
Mailing Address - Country:US
Mailing Address - Phone:479-567-5746
Mailing Address - Fax:
Practice Address - Street 1:10668 LYDIA LN
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:AR
Practice Address - Zip Code:72833-6890
Practice Address - Country:US
Practice Address - Phone:479-496-6326
Practice Address - Fax:473-495-3336
Is Sole Proprietor?:No
Enumeration Date:2008-10-16
Last Update Date:2008-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARSP2612235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR09139851OtherAMERICAN ST, LANG, ASSOC
AR170086721Medicaid
ARSP2612OtherAR STATE LICENSE