Provider Demographics
NPI:1457436834
Name:ROGERS, PENNY MELLARD (LCSW)
Entity Type:Individual
Prefix:
First Name:PENNY
Middle Name:MELLARD
Last Name:ROGERS
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 1:303 E MATTHEWS AVE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72401-3150
Mailing Address - Country:US
Mailing Address - Phone:870-207-7555
Mailing Address - Fax:870-336-5083
Practice Address - Street 1:303 E MATTHEWS AVE
Practice Address - Street 2:SUITE 202
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-3150
Practice Address - Country:US
Practice Address - Phone:870-207-7555
Practice Address - Fax:870-336-5083
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2014-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2087-C1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR248153YJNYMedicare UPIN