Healthcare Provider Details

I. General information

NPI: 1912098260
Provider Name (Legal Business Name): LICIA WILLIAMS ROGERS LPA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/28/2006
Last Update Date: 06/12/2020
Certification Date: 06/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4020 OLEANDER DR STE 203
WILMINGTON NC
28403-6850
US

IV. Provider business mailing address

4020 OLEANDER DR STE 203
WILMINGTON NC
28403-6850
US

V. Phone/Fax

Practice location:
  • Phone: 910-540-8081
  • Fax: 910-399-3434
Mailing address:
  • Phone: 910-540-8081
  • Fax: 910-399-3434

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number1980
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number1980
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: