MEDICARE: MS. THERESA MARIE ROGERS M.S.W,

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	LW00004110	WA

General Provider Information

NPI Number	:	1457563561
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. THERESA MARIE ROGERS M.S.W,

Provider Business Mailing Address
First Line	:	1921 BIGELOW AVE N
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98109-2622
Country	:	US
Telephone Number	:	206-548-1223
Fax Number	:	206-632-4467

Provider Business Practice Location Address
First Line	:	3876 BRIDGE WAY N
Second Line	:	SUITE 200
City	:	SEATTLE
State	:	WA
Zip	:	98103-7951
Country	:	US
Telephone Number	:	206-548-1223
Fax Number	:	206-632-4467

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/03/2007
Last Update Date	:	07/08/2007

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