Healthcare Provider Details

I. General information

NPI: 1841553286
Provider Name (Legal Business Name): MICHAEL BRANDON ROGERS LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2012
Last Update Date: 09/07/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 FORT ROOTS DR
NORTH LITTLE ROCK AR
72114
US

IV. Provider business mailing address

6 EMERALD CT
LITTLE ROCK AR
72212-2107
US

V. Phone/Fax

Practice location:
  • Phone: 501-257-3091
  • Fax:
Mailing address:
  • Phone: 501-612-7877
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6653-C
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License NumberPROVISIONAL (PLMSW)
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: