Healthcare Provider Details

I. General information

NPI: 1104982859
Provider Name (Legal Business Name): RANDI MICHELLE ROGGEMAN LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: RANDI MICHELLE HERMAN-ROGGEMAN MC

II. Dates (important events)

Enumeration Date: 12/28/2006
Last Update Date: 09/13/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 S. POWER RD STE 108
MESA AZ
85209
US

IV. Provider business mailing address

2500 S. POWER RD STE 108
MESA AZ
85209
US

V. Phone/Fax

Practice location:
  • Phone: 480-985-0333
  • Fax: 480-768-1564
Mailing address:
  • Phone: 480-985-0333
  • Fax: 480-768-1564

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberLPC-2209
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPC-2209
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: