Healthcare Provider Details

I. General information

NPI: 1275321663
Provider Name (Legal Business Name): MARY ANNA-FORREST ROGERS
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2025
Last Update Date: 04/28/2025
Certification Date: 04/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2176 PARK AVE STE 102
ORANGE PARK FL
32073-5586
US

IV. Provider business mailing address

2176 PARK AVE STE 102
ORANGE PARK FL
32073-5586
US

V. Phone/Fax

Practice location:
  • Phone: 904-297-0054
  • Fax:
Mailing address:
  • Phone: 904-297-0054
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: