=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740461631
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DALE D RODGERS CDP
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/19/2007
-----------------------------------------------------
Last Update Date | 11/19/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1203 PROSSER AVE
-----------------------------------------------------
City | PROSSER
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 99350-1430
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 509-544-5726
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3918 W COURT ST
-----------------------------------------------------
City | PASCO
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 99301-2775
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 509-547-8441
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | CP00001038
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------