Provider Demographics
NPI:1972288058
Name:ROGERS, JOHN DAVID (LISAC)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:DAVID
Last Name:ROGERS
Suffix:
Gender:M
Credentials:LISAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11645 N 25TH PL APT 130
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85028-1847
Mailing Address - Country:US
Mailing Address - Phone:480-594-7186
Mailing Address - Fax:
Practice Address - Street 1:4801 S LAKESHORE DR STE 102
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85282-7156
Practice Address - Country:US
Practice Address - Phone:480-594-7186
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-16
Last Update Date:2023-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLISAC11726101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)