Provider Demographics
NPI:1316345242
Name:ROGERS, TIFFANY SHANETTE (LCMHCS)
Entity type:Individual
Prefix:MRS
First Name:TIFFANY
Middle Name:SHANETTE
Last Name:ROGERS
Suffix:
Gender:F
Credentials:LCMHCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2443 LYNN RD STE 112
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27612-6759
Mailing Address - Country:US
Mailing Address - Phone:984-280-2474
Mailing Address - Fax:919-891-6896
Practice Address - Street 1:2443 LYNN RD STE 112
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27612-6759
Practice Address - Country:US
Practice Address - Phone:984-280-2474
Practice Address - Fax:919-891-6896
Is Sole Proprietor?:No
Enumeration Date:2014-12-09
Last Update Date:2024-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCS12780101YP2500X
NCA12780101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC$$$$$$$$$Medicaid