Provider Demographics
NPI:1720659444
Name:ROGERS, DYLAN (LPC)
Entity Type:Individual
Prefix:
First Name:DYLAN
Middle Name:
Last Name:ROGERS
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2118 S KERR ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83705-3414
Mailing Address - Country:US
Mailing Address - Phone:651-334-9896
Mailing Address - Fax:
Practice Address - Street 1:4615 W EMERALD ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-2002
Practice Address - Country:US
Practice Address - Phone:208-344-2228
Practice Address - Fax:208-930-1695
Is Sole Proprietor?:No
Enumeration Date:2021-07-03
Last Update Date:2022-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID8245101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional