Basic Information
| Provider Information | |||||||||
| NPI: | 1144292178 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RODGERS | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | W | ||||||||
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| Credential: | EDD LP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8100 34TH AVE S | ||||||||
| Address2: | MC21110Q | ||||||||
| City: | BLOOMINGTON | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554251672 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9528837172 | ||||||||
| FaxNumber: | 9528835395 | ||||||||
| Practice Location | |||||||||
| Address1: | 5625 CENEX DR | ||||||||
| Address2: | MAIL STOP 33100A | ||||||||
| City: | INVER GROVES HEIGHTS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 550771735 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6515522600 | ||||||||
| FaxNumber: | 6515522674 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/03/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 2265 | MN | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.