Provider Demographics
NPI:1316492168
Name:ROGERS, LISA MARIE
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:MARIE
Last Name: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 1:3602 SEACREST WAY
Mailing Address - Street 2:
Mailing Address - City:OCEANSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92056-5027
Mailing Address - Country:US
Mailing Address - Phone:760-696-1994
Mailing Address - Fax:
Practice Address - Street 1:1100 SPORTFISHER DR
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:CA
Practice Address - Zip Code:92054-2550
Practice Address - Country:US
Practice Address - Phone:760-439-6702
Practice Address - Fax:760-439-4779
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-22
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)