Provider Demographics
NPI:1306362066
Name:DALLAS ROGERS, MOLLY JANE
Entity type:Individual
Prefix:
First Name:MOLLY
Middle Name:JANE
Last Name:DALLAS ROGERS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7281 BEAVER RUN DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28314-5188
Mailing Address - Country:US
Mailing Address - Phone:785-643-3202
Mailing Address - Fax:
Practice Address - Street 1:375 SE BROAD ST
Practice Address - Street 2:
Practice Address - City:SOUTHERN PINES
Practice Address - State:NC
Practice Address - Zip Code:28387-6057
Practice Address - Country:US
Practice Address - Phone:910-725-0702
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-15
Last Update Date:2023-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X, 106S00000X
NC314103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician