Healthcare Provider Details

I. General information

NPI: 1689462459
Provider Name (Legal Business Name): D'ANDRAE RODGERS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/30/2025
Last Update Date: 04/30/2025
Certification Date: 04/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1705 WOODLAND ST NE
WARREN OH
44483-5348
US

IV. Provider business mailing address

1705 WOODLAND ST NE
WARREN OH
44483-5348
US

V. Phone/Fax

Practice location:
  • Phone: 330-469-6777
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: