Provider Demographics
NPI:1174539688
Name:ROGERS, CAMILLA (PHD)
Entity type:Individual
Prefix:
First Name:CAMILLA
Middle Name:
Last Name:ROGERS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:869 WENDOVER RD
Mailing Address - Street 2:
Mailing Address - City:STATESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28677-3141
Mailing Address - Country:US
Mailing Address - Phone:704-380-0436
Mailing Address - Fax:866-950-6464
Practice Address - Street 1:121 N CENTER ST STE 202
Practice Address - Street 2:
Practice Address - City:STATESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28677-5388
Practice Address - Country:US
Practice Address - Phone:704-380-0436
Practice Address - Fax:866-950-6464
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2023-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3551102L00000X, 103T00000X, 103TA0700X, 103TB0200X, 103TP0814X, 103TP2701X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No102L00000XBehavioral Health & Social Service ProvidersPsychoanalyst
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & Aging
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TP0814XBehavioral Health & Social Service ProvidersPsychologistPsychoanalysis
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2826089OtherMEDICARE PTAN