Basic Information
| Provider Information | |||||||||
| NPI: | 1093858755 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROGERS | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | KATELYN | ||||||||
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| Credential: | LPCC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1080 | ||||||||
| Address2: | |||||||||
| City: | BURKESVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 427171080 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2708586655 | ||||||||
| FaxNumber: | 2708584027 | ||||||||
| Practice Location | |||||||||
| Address1: | 426 COMMERCE DRIVE | ||||||||
| Address2: | |||||||||
| City: | GREENSBURG | ||||||||
| State: | KY | ||||||||
| PostalCode: | 42743 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2702992222 | ||||||||
| FaxNumber: | 2702992211 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/14/2007 | ||||||||
| LastUpdateDate: | 06/30/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 103576 | KY | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 30605018 | 05 | KY | MEDICAID | 7100289710 | 05 | KY | MEDICAID |