Basic Information
| Provider Information | |||||||||
| NPI: | 1215669247 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROGERS | ||||||||
| FirstName: | EDWARD | ||||||||
| MiddleName: | DALE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1900 VICKI LN | ||||||||
| Address2: | |||||||||
| City: | NORFOLK | ||||||||
| State: | NE | ||||||||
| PostalCode: | 687014558 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4023703140 | ||||||||
| FaxNumber: | 4023703373 | ||||||||
| Practice Location | |||||||||
| Address1: | 1900 VICKI LN | ||||||||
| Address2: | |||||||||
| City: | NORFOLK | ||||||||
| State: | NE | ||||||||
| PostalCode: | 687014558 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4023703140 | ||||||||
| FaxNumber: | 4023703373 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2022 | ||||||||
| LastUpdateDate: | 06/28/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | P-1985 | NE | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.