Provider Demographics
NPI:1730360975
Name:ROGERS, REBECCA A (MH COUNSELOR)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:A
Last Name:ROGERS
Suffix:
Gender:F
Credentials:MH COUNSELOR
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:A
Other - Last Name:MANLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:565 CLOVER DR
Mailing Address - Street 2:
Mailing Address - City:UPPER LAKE
Mailing Address - State:CA
Mailing Address - Zip Code:95485-9233
Mailing Address - Country:US
Mailing Address - Phone:707-275-9555
Mailing Address - Fax:
Practice Address - Street 1:565 CLOVER DR
Practice Address - Street 2:
Practice Address - City:UPPER LAKE
Practice Address - State:CA
Practice Address - Zip Code:95485-9233
Practice Address - Country:US
Practice Address - Phone:707-275-9555
Practice Address - Fax:707-275-9555
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-15
Last Update Date:2011-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
CAAMF06116104101YP1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral