Provider Demographics
NPI:1215443544
Name:HAWKINS, ROGER DALE (LISW-S, LICDC-CS)
Entity type:Individual
Prefix:
First Name:ROGER
Middle Name:DALE
Last Name:HAWKINS
Suffix:
Gender:M
Credentials:LISW-S, LICDC-CS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2898 MYERS RD
Mailing Address - Street 2:
Mailing Address - City:SHELBY
Mailing Address - State:OH
Mailing Address - Zip Code:44875-9401
Mailing Address - Country:US
Mailing Address - Phone:419-565-0053
Mailing Address - Fax:
Practice Address - Street 1:2775 STATE ROUTE 39
Practice Address - Street 2:
Practice Address - City:SHELBY
Practice Address - State:OH
Practice Address - Zip Code:44875-9466
Practice Address - Country:US
Practice Address - Phone:419-747-3322
Practice Address - Fax:419-747-3504
Is Sole Proprietor?:No
Enumeration Date:2017-12-22
Last Update Date:2024-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLICDC.161393101YA0400X
OHI.2102610-SUPV1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)