Provider Demographics
NPI:1437323235
Name:DANIELS, ROGER EUGENE (DMIN)
Entity type:Individual
Prefix:MR
First Name:ROGER
Middle Name:EUGENE
Last Name:DANIELS
Suffix:
Gender:M
Credentials:DMIN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9311 E SPEEDWAY BLVD
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85710-1822
Mailing Address - Country:US
Mailing Address - Phone:217-454-3509
Mailing Address - Fax:
Practice Address - Street 1:6979 E BROADWAY BLVD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85710-2800
Practice Address - Country:US
Practice Address - Phone:520-800-9108
Practice Address - Fax:520-722-9175
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-14
Last Update Date:2021-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.000325101Y00000X
AZLAC-18751101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor