Provider Demographics
NPI:1215099163
Name:ROGERS, KENNETH EMERSON (PSYD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:EMERSON
Last Name:ROGERS
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9324 W STOCKTON BLVD
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95758-8012
Mailing Address - Country:US
Mailing Address - Phone:916-478-7716
Mailing Address - Fax:916-478-7760
Practice Address - Street 1:9324 W STOCKTON BLVD
Practice Address - Street 2:
Practice Address - City:ELK GROVE
Practice Address - State:CA
Practice Address - Zip Code:95758-8012
Practice Address - Country:US
Practice Address - Phone:916-478-7716
Practice Address - Fax:916-478-7760
Is Sole Proprietor?:No
Enumeration Date:2006-12-15
Last Update Date:2022-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20122103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical