Provider Demographics
NPI:1962162024
Name:ROGERS, COLLEEN (PTA)
Entity type:Individual
Prefix:MRS
First Name:COLLEEN
Middle Name:
Last Name:ROGERS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 DOG RANCH RD
Mailing Address - Street 2:
Mailing Address - City:LA LUZ
Mailing Address - State:NM
Mailing Address - Zip Code:88337-9411
Mailing Address - Country:US
Mailing Address - Phone:575-499-5539
Mailing Address - Fax:
Practice Address - Street 1:1809 INDIAN WELLS RD
Practice Address - Street 2:
Practice Address - City:ALAMOGORDO
Practice Address - State:NM
Practice Address - Zip Code:88310-4617
Practice Address - Country:US
Practice Address - Phone:575-437-1967
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-30
Last Update Date:2021-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMA-2110225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant