Healthcare Provider Details

I. General information

NPI: 1679766075
Provider Name (Legal Business Name): LAURA LYNN ROGERS LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/20/2007
Last Update Date: 12/18/2024
Certification Date: 12/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4244 CHEROKEE AVE APT 7
SAN DIEGO CA
92104-6602
US

IV. Provider business mailing address

4244 CHEROKEE AVE APT 7
SAN DIEGO CA
92104-6602
US

V. Phone/Fax

Practice location:
  • Phone: 619-507-6200
  • Fax:
Mailing address:
  • Phone: 619-507-6200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149.011920
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number27262
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number075240
License Number StateNY
# 4
Primary TaxonomyN
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number
License Number StateNY
# 5
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: