Healthcare Provider Details

I. General information

NPI: 1174358436
Provider Name (Legal Business Name): KHAMARI RODGERS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/05/2024
Last Update Date: 09/05/2024
Certification Date: 09/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1622 S BLUE ISLAND AVE
CHICAGO IL
60608-2238
US

IV. Provider business mailing address

18437 CALIFORNIA AVE
HOMEWOOD IL
60430-2814
US

V. Phone/Fax

Practice location:
  • Phone: 312-584-0559
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number23-271462
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: