Provider Demographics
NPI:1700612298
Name:ROGERS, KELLIE MARIE (MA, LPC)
Entity type:Individual
Prefix:
First Name:KELLIE
Middle Name:MARIE
Last Name:ROGERS
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 W OAK AVE
Mailing Address - Street 2:
Mailing Address - City:WINNIE
Mailing Address - State:TX
Mailing Address - Zip Code:77665-8365
Mailing Address - Country:US
Mailing Address - Phone:409-201-1517
Mailing Address - Fax:
Practice Address - Street 1:11340 EAGLE DR STE 4
Practice Address - Street 2:
Practice Address - City:MONT BELVIEU
Practice Address - State:TX
Practice Address - Zip Code:77523-7630
Practice Address - Country:US
Practice Address - Phone:409-201-1517
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-11
Last Update Date:2024-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX87434103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Multi-Specialty