Healthcare Provider Details

I. General information

NPI: 1912695222
Provider Name (Legal Business Name): MINA RODGERS LPC, NCC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/25/2023
Last Update Date: 04/27/2023
Certification Date: 04/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3506 PROFESSIONAL CIR STE B
MARTINEZ GA
30907-8234
US

IV. Provider business mailing address

3633 WHEELER RD # 365
AUGUSTA GA
30909-6549
US

V. Phone/Fax

Practice location:
  • Phone: 706-210-8855
  • Fax:
Mailing address:
  • Phone: 678-778-6089
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPC013787
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC013787
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: