Basic Information
| Provider Information | |||||||||
| NPI: | 1750889168 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RODGERS | ||||||||
| FirstName: | KIM | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | LICSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8609 EVERGREEN WAY | ||||||||
| Address2: | |||||||||
| City: | EVERETT | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982082619 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4257893700 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4201 RUCKER AVE | ||||||||
| Address2: | |||||||||
| City: | EVERETT | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982032215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4253824000 | ||||||||
| FaxNumber: | 4253824001 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/31/2018 | ||||||||
| LastUpdateDate: | 01/20/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/20/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | LW60048741 | WA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.