Healthcare Provider Details

I. General information

NPI: 1497247902
Provider Name (Legal Business Name): BARON KENLEY ROGERS PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/31/2018
Last Update Date: 07/19/2023
Certification Date: 07/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 HIGH MEADOW CT
STATE COLLEGE PA
16803-1889
US

IV. Provider business mailing address

125 HIGH MEADOW CT
STATE COLLEGE PA
16803-1889
US

V. Phone/Fax

Practice location:
  • Phone: 330-814-1235
  • Fax:
Mailing address:
  • Phone: 330-814-1235
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License NumberPS019938
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: