Provider Demographics
NPI:1285706507
Name:ROGERS, LISA (LP)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:ROGERS
Suffix:
Gender:F
Credentials:LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 CLEVELAND AVE S
Mailing Address - Street 2:STE 201
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55116-3845
Mailing Address - Country:US
Mailing Address - Phone:651-645-5323
Mailing Address - Fax:651-647-5135
Practice Address - Street 1:790 CLEVELAND AVE S STE 201
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55116-3845
Practice Address - Country:US
Practice Address - Phone:612-808-9730
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2020-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP3260103TC0700X
MN3260103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical