Provider Demographics
NPI:1194775841
Name:ROGERS-TANNER, CAROL (MS LP)
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:
Last Name:ROGERS-TANNER
Suffix:
Gender:F
Credentials:MS LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2399 ARIEL ST N STE D
Mailing Address - Street 2:
Mailing Address - City:MAPLEWOOD
Mailing Address - State:MN
Mailing Address - Zip Code:55109-2202
Mailing Address - Country:US
Mailing Address - Phone:651-770-1311
Mailing Address - Fax:651-770-1879
Practice Address - Street 1:2399 ARIEL ST N STE D
Practice Address - Street 2:
Practice Address - City:MAPLEWOOD
Practice Address - State:MN
Practice Address - Zip Code:55109-2202
Practice Address - Country:US
Practice Address - Phone:651-770-1311
Practice Address - Fax:651-770-1879
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-11
Last Update Date:2015-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP2901103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN857051500Medicaid