Provider Demographics
NPI:1366789695
Name:ROGERS, DELISA MICHELLE
Entity type:Individual
Prefix:MISS
First Name:DELISA
Middle Name:MICHELLE
Last Name:ROGERS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7713 NW 113TH PL
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73162-2542
Mailing Address - Country:US
Mailing Address - Phone:405-615-4974
Mailing Address - Fax:
Practice Address - Street 1:625 NW 13TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73103-2239
Practice Address - Country:US
Practice Address - Phone:405-601-2307
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-07
Last Update Date:2013-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200077440AMedicaid