Provider Demographics
NPI:1306259270
Name:ROGERS, MICHELE
Entity type:Individual
Prefix:
First Name:MICHELE
Middle Name:
Last Name:ROGERS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:68 CARMELLA DR
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60012-3517
Mailing Address - Country:US
Mailing Address - Phone:815-715-8757
Mailing Address - Fax:
Practice Address - Street 1:68 CARMELLA DR
Practice Address - Street 2:
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60012-3517
Practice Address - Country:US
Practice Address - Phone:815-715-8757
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-08
Last Update Date:2014-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490155801041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL149015580OtherPROFESSIONAL CLINICAL SOCIAL WORK LICENSE NUMBER