Basic Information
| Provider Information | |||||||||
| NPI: | 1023744380 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROGERS | ||||||||
| FirstName: | PATRICIA | ||||||||
| MiddleName: | WHITE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LMSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WHITE | ||||||||
| OtherFirstName: | PATRICIA | ||||||||
| OtherMiddleName: | S | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LMSW | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 607 | ||||||||
| Address2: | |||||||||
| City: | CANTON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 390460607 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6018599888 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1171 HART ST | ||||||||
| Address2: | |||||||||
| City: | CANTON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 390464805 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6018599888 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2022 | ||||||||
| LastUpdateDate: | 07/28/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 15405 | MS | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 15405 | 01 | MS | 261QR1300X - CLINIC/CENTER RURAL HEALTH | OTHER |