MEDICARE: GREGORY DEREK RODGERS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	1184	WV

General Provider Information

NPI Number	:	1326995911
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GREGORY DEREK RODGERS

Provider Business Mailing Address
First Line	:	513 NANCY ST
Second Line	:
City	:	CHARLESTON
State	:	WV
Zip	:	25311-2005
Country	:	US
Telephone Number	:	270-792-4665
Fax Number	:

Provider Business Practice Location Address
First Line	:	513 NANCY ST
Second Line	:
City	:	CHARLESTON
State	:	WV
Zip	:	25311-2005
Country	:	US
Telephone Number	:	270-792-4665
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/12/2026
Last Update Date	:	03/12/2026

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