Healthcare Provider Details

I. General information

NPI: 1962692616
Provider Name (Legal Business Name): WILBUR ROGERS MA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/30/2007
Last Update Date: 07/30/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1903 GADSDEN ST STE 204
COLUMBIA SC
29201-2352
US

IV. Provider business mailing address

1903 GADSDEN ST STE 204
COLUMBIA SC
29201-2352
US

V. Phone/Fax

Practice location:
  • Phone: 803-254-9767
  • Fax: 803-254-9740
Mailing address:
  • Phone: 803-254-9767
  • Fax: 803-254-9740

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number4808
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: