MEDICARE: SHANETTE ROGERS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	P010005	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	P010005	OTHER	NC	LCSW-A

General Provider Information

NPI Number	:	1356719280
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHANETTE ROGERS

Provider Business Mailing Address
First Line	:	3703 LATROBE DR
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28211-1363
Country	:	US
Telephone Number	:	704-371-3050
Fax Number	:

Provider Business Practice Location Address
First Line	:	3703 LATROBE DR
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28211-1363
Country	:	US
Telephone Number	:	704-371-3050
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/09/2015
Last Update Date	:	09/09/2015

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Directions to “ SHANETTE ROGERS ” Practice Location

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