Provider Demographics
NPI:1578028171
Name:ROGERS, KRYSTINA ELISE (LAC)
Entity type:Individual
Prefix:
First Name:KRYSTINA
Middle Name:ELISE
Last Name:ROGERS
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 CANNA ST
Mailing Address - Street 2:
Mailing Address - City:BROWNS MILLS
Mailing Address - State:NJ
Mailing Address - Zip Code:08015-2075
Mailing Address - Country:US
Mailing Address - Phone:848-992-9930
Mailing Address - Fax:
Practice Address - Street 1:2083 KLOCKNER RD
Practice Address - Street 2:
Practice Address - City:TRENTON
Practice Address - State:NJ
Practice Address - Zip Code:08690-3415
Practice Address - Country:US
Practice Address - Phone:609-222-4902
Practice Address - Fax:640-888-7533
Is Sole Proprietor?:No
Enumeration Date:2019-02-07
Last Update Date:2024-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJAD-GTL-22-02716101YA0400X
101YM0800X
NJ37AC00770600101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)