Provider Demographics
NPI:1255940979
Name:ROGERS, SALLY ANN
Entity type:Individual
Prefix:MS
First Name:SALLY
Middle Name:ANN
Last Name:ROGERS
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 1:75 KUAHIWI AVE
Mailing Address - Street 2:
Mailing Address - City:WAHIAWA
Mailing Address - State:HI
Mailing Address - Zip Code:96786-1905
Mailing Address - Country:US
Mailing Address - Phone:530-941-1913
Mailing Address - Fax:
Practice Address - Street 1:2226 LILIHA ST STE 403
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96817-1605
Practice Address - Country:US
Practice Address - Phone:888-657-4456
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-28
Last Update Date:2020-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIRBT-20-119065106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician