Provider Demographics
NPI:1053167080
Name:RODGERS, CRYSTAL MARIE (CPSS)
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:MARIE
Last Name:RODGERS
Suffix:
Gender:F
Credentials:CPSS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:756 TYVOLA RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28217-3588
Mailing Address - Country:US
Mailing Address - Phone:980-265-1001
Mailing Address - Fax:
Practice Address - Street 1:756 TYVOLA RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28217-3588
Practice Address - Country:US
Practice Address - Phone:980-265-1001
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-29
Last Update Date:2024-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2022-7765-01175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist