Provider Demographics
NPI:1467222794
Name:RODGERS, KELLY RENAY
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:RENAY
Last Name:RODGERS
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 1:107 N ASHFORD ST
Mailing Address - Street 2:
Mailing Address - City:SAVOY
Mailing Address - State:TX
Mailing Address - Zip Code:75479-2301
Mailing Address - Country:US
Mailing Address - Phone:903-805-8744
Mailing Address - Fax:
Practice Address - Street 1:2612 W LAMBERTH RD
Practice Address - Street 2:
Practice Address - City:SHERMAN
Practice Address - State:TX
Practice Address - Zip Code:75092-5179
Practice Address - Country:US
Practice Address - Phone:254-249-6530
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-08
Last Update Date:2025-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXRBT-24-320608106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician