Provider Demographics
NPI:1669943163
Name:ROGERS, KIZZY MISHEE'
Entity type:Individual
Prefix:
First Name:KIZZY
Middle Name:MISHEE'
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:PO BOX 754207
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38175-4207
Mailing Address - Country:US
Mailing Address - Phone:901-207-6946
Mailing Address - Fax:
Practice Address - Street 1:3385 AUSTIN PEAY HWY STE 115
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38128-3810
Practice Address - Country:US
Practice Address - Phone:901-207-6946
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-09
Last Update Date:2021-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN111271041S0200X
104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool