Provider Demographics
NPI:1396913067
Name:ROGERS, MATTIE (SPEECH THERAPIST)
Entity type:Individual
Prefix:
First Name:MATTIE
Middle Name:
Last Name:ROGERS
Suffix:
Gender:F
Credentials:SPEECH THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2300 BILL OWENS PKWY APT 322
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75604-3069
Mailing Address - Country:US
Mailing Address - Phone:903-918-5806
Mailing Address - Fax:903-295-5803
Practice Address - Street 1:107 WOODBINE PL
Practice Address - Street 2:UNIT 775
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75601-2912
Practice Address - Country:US
Practice Address - Phone:903-918-5806
Practice Address - Fax:903-295-5803
Is Sole Proprietor?:No
Enumeration Date:2008-02-15
Last Update Date:2008-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX13105235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX6665448211Medicaid