Provider Demographics
NPI:1912098260
Name:ROGERS, LICIA WILLIAMS (LPA)
Entity Type:Individual
Prefix:MRS
First Name:LICIA
Middle Name:WILLIAMS
Last Name:ROGERS
Suffix:
Gender:F
Credentials:LPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4020 OLEANDER DR STE 203
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28403-6850
Mailing Address - Country:US
Mailing Address - Phone:910-540-8081
Mailing Address - Fax:910-399-3434
Practice Address - Street 1:4020 OLEANDER DR STE 203
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-6850
Practice Address - Country:US
Practice Address - Phone:910-540-8081
Practice Address - Fax:910-399-3434
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2020-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1980103TC0700X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6107193Medicaid