Healthcare Provider Details

I. General information

NPI: 1124539978
Provider Name (Legal Business Name): EVELYN VIRGINIA ROGERS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/19/2017
Last Update Date: 10/19/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12647 OLIVE BLVD STE 600
SAINT LOUIS MO
63141-6346
US

IV. Provider business mailing address

12647 OLIVE BLVD STE 600
SAINT LOUIS MO
63141-6346
US

V. Phone/Fax

Practice location:
  • Phone: 800-325-3982
  • Fax: 888-685-9880
Mailing address:
  • Phone: 800-325-3982
  • Fax: 888-685-9880

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number0897
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: