Provider Demographics
NPI:1194933069
Name:RODGERS, IDA LEARY (LCSW)
Entity type:Individual
Prefix:MRS
First Name:IDA
Middle Name:LEARY
Last Name:RODGERS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 TERRY ST
Mailing Address - Street 2:
Mailing Address - City:ELIZABETH CITY
Mailing Address - State:NC
Mailing Address - Zip Code:27909-9745
Mailing Address - Country:US
Mailing Address - Phone:252-335-9130
Mailing Address - Fax:
Practice Address - Street 1:1221 CAROLINA AVE STE 8
Practice Address - Street 2:
Practice Address - City:ELIZABETH CITY
Practice Address - State:NC
Practice Address - Zip Code:27909-5407
Practice Address - Country:US
Practice Address - Phone:252-340-4987
Practice Address - Fax:252-331-2849
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCCOO56531041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical