Healthcare Provider Details

I. General information

NPI: 1174539688
Provider Name (Legal Business Name): CAMILLA ROGERS PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/01/2006
Last Update Date: 06/05/2023
Certification Date: 06/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 N CENTER ST STE 202
STATESVILLE NC
28677-5388
US

IV. Provider business mailing address

869 WENDOVER RD
STATESVILLE NC
28677-3141
US

V. Phone/Fax

Practice location:
  • Phone: 704-380-0436
  • Fax: 866-950-6464
Mailing address:
  • Phone: 704-380-0436
  • Fax: 866-950-6464

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code102L00000X
TaxonomyPsychoanalyst
License Number3551
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number3551
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code103TA0700X
TaxonomyAdult Development & Aging Psychologist
License Number3551
License Number StateNC
# 4
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number3551
License Number StateNC
# 5
Primary TaxonomyN
Taxonomy Code103TP0814X
TaxonomyPsychoanalysis Psychologist
License Number3551
License Number StateNC
# 6
Primary TaxonomyN
Taxonomy Code103TP2701X
TaxonomyGroup Psychotherapy Psychologist
License Number3551
License Number StateNC
# 7
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number3551
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: