Provider Demographics
NPI:1679119424
Name:ROGERS, DEWAYNE LAVONTE I
Entity type:Individual
Prefix:MR
First Name:DEWAYNE
Middle Name:LAVONTE
Last Name:ROGERS
Suffix:I
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 COMMON ST APT 1L
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:MA
Mailing Address - Zip Code:02169-1663
Mailing Address - Country:US
Mailing Address - Phone:857-251-8996
Mailing Address - Fax:
Practice Address - Street 1:132 ROBBS HILL RD
Practice Address - Street 2:
Practice Address - City:LUNENBURG
Practice Address - State:MA
Practice Address - Zip Code:01462-2167
Practice Address - Country:US
Practice Address - Phone:774-270-1766
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-26
Last Update Date:2019-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAS55356645106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician