Healthcare Provider Details

I. General information

NPI: 1164751236
Provider Name (Legal Business Name): COLLEEN ANN ROGANOVICH SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/18/2009
Last Update Date: 12/18/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4003 VICTORIA DR
VALPARAISO IN
46383-2092
US

IV. Provider business mailing address

4003 VICTORIA DR
VALPARAISO IN
46383-2092
US

V. Phone/Fax

Practice location:
  • Phone: 219-476-0023
  • Fax:
Mailing address:
  • Phone: 219-476-0023
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number22001963A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: