Provider Demographics
NPI:1154729523
Name:ROGERS, DIANE M (PSYD)
Entity type:Individual
Prefix:DR
First Name:DIANE
Middle Name:M
Last Name:ROGERS
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17302 GREEN RD
Mailing Address - Street 2:
Mailing Address - City:HARVARD
Mailing Address - State:IL
Mailing Address - Zip Code:60033-9625
Mailing Address - Country:US
Mailing Address - Phone:815-572-1181
Mailing Address - Fax:
Practice Address - Street 1:17302 GREEN RD
Practice Address - Street 2:
Practice Address - City:HARVARD
Practice Address - State:IL
Practice Address - Zip Code:60033-9625
Practice Address - Country:US
Practice Address - Phone:815-572-1181
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-16
Last Update Date:2014-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071.007857103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical