Healthcare Provider Details

I. General information

NPI: 1003617473
Provider Name (Legal Business Name): BRENDA RODGERS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2025
Last Update Date: 03/21/2025
Certification Date: 03/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1420 CHANDLER DR
CHARLESTON WV
25387-1605
US

IV. Provider business mailing address

114 E MAIN ST
BECKLEY WV
25801-4706
US

V. Phone/Fax

Practice location:
  • Phone: 681-341-4536
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number25-920SUD
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: