Basic Information
| Provider Information | |||||||||
| NPI: | 1902029010 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROGERS | ||||||||
| FirstName: | THERESA | ||||||||
| MiddleName: | ADKINS | ||||||||
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| Credential: | MASTERS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10622 FERRY LAKE SCHOOL RD | ||||||||
| Address2: | |||||||||
| City: | OIL CITY | ||||||||
| State: | LA | ||||||||
| PostalCode: | 710619628 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1310 N HEARNE AVE | ||||||||
| Address2: | |||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711076516 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3186765111 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 0728 | 01 | LA | OMH PROVIDER NUMBER | OTHER |