Healthcare Provider Details

I. General information

NPI: 1730696782
Provider Name (Legal Business Name): NICOLE M ROGERS LSCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/29/2017
Last Update Date: 12/29/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

635 N MAIN ST
WICHITA KS
67203-3602
US

IV. Provider business mailing address

271 W 3RD ST N STE 600
WICHITA KS
67202-1212
US

V. Phone/Fax

Practice location:
  • Phone: 316-660-7525
  • Fax: 316-660-1897
Mailing address:
  • Phone: 316-660-7600
  • Fax: 316-941-5075

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2349
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: