Healthcare Provider Details

I. General information

NPI: 1023625761
Provider Name (Legal Business Name): GEORGIE IRENE ROGERS M.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2020
Last Update Date: 06/16/2023
Certification Date: 06/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 W WALNUT ST STE 375
PASADENA CA
91124-0001
US

IV. Provider business mailing address

100 W WALNUT ST STE 375
PASADENA CA
91124-0001
US

V. Phone/Fax

Practice location:
  • Phone: 626-395-7100
  • Fax:
Mailing address:
  • Phone: 626-395-7100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number121683
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number139927
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: