Provider Demographics
NPI:1295560191
Name:ROGERS, PERSEPHONE (MS, LSSP, NCSP)
Entity type:Individual
Prefix:
First Name:PERSEPHONE
Middle Name:
Last Name:ROGERS
Suffix:
Gender:F
Credentials:MS, LSSP, NCSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2803 RIVERSIDE PKWY APT 5203
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75050-8748
Mailing Address - Country:US
Mailing Address - Phone:713-208-1379
Mailing Address - Fax:
Practice Address - Street 1:2803 RIVERSIDE PKWY APT 5203
Practice Address - Street 2:
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75050-8748
Practice Address - Country:US
Practice Address - Phone:713-208-1379
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-03
Last Update Date:2024-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX72874103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool