Provider Demographics
NPI:1588287783
Name:RODGERS, SHELBY LYN
Entity type:Individual
Prefix:
First Name:SHELBY
Middle Name:LYN
Last Name:RODGERS
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 1:534 ELMHURST DR
Mailing Address - Street 2:
Mailing Address - City:PORT LAVACA
Mailing Address - State:TX
Mailing Address - Zip Code:77979-2316
Mailing Address - Country:US
Mailing Address - Phone:361-482-9851
Mailing Address - Fax:
Practice Address - Street 1:4702 N LAURENT ST
Practice Address - Street 2:
Practice Address - City:VICTORIA
Practice Address - State:TX
Practice Address - Zip Code:77904-2147
Practice Address - Country:US
Practice Address - Phone:361-572-0202
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-21
Last Update Date:2020-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX79857101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional