Healthcare Provider Details

I. General information

NPI: 1134983497
Provider Name (Legal Business Name): PENNY ROGERS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/07/2024
Last Update Date: 10/21/2025
Certification Date: 10/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

848 W EASTMAN ST STE 103
CHICAGO IL
60642-2635
US

IV. Provider business mailing address

848 W EASTMAN ST STE 103
CHICAGO IL
60642-2635
US

V. Phone/Fax

Practice location:
  • Phone: 312-702-2303
  • Fax:
Mailing address:
  • Phone: 312-702-2303
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number178022006
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: