Basic Information
| Provider Information | |||||||||
| NPI: | 1043459399 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RODGERS | ||||||||
| FirstName: | CHAD | ||||||||
| MiddleName: | A | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1323 W COLTON AVE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | REDLANDS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923744554 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9097920747 | ||||||||
| FaxNumber: | 9097922045 | ||||||||
| Practice Location | |||||||||
| Address1: | 15447 ANACAPA RD | ||||||||
| Address2: | SUITE 104 | ||||||||
| City: | VICTORVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923922481 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7602459446 | ||||||||
| FaxNumber: | 7907518986 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/10/2009 | ||||||||
| LastUpdateDate: | 02/10/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | Y | Behavioral Health & Social Service Providers | Counselor |
No ID Information.