Healthcare Provider Details

I. General information

NPI: 1619218195
Provider Name (Legal Business Name): KRISTEN NICOLE ROGERS LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/08/2013
Last Update Date: 08/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

648 MONROE AVE NW SUITE 216
GRAND RAPIDS MI
49503-1452
US

IV. Provider business mailing address

648 MONROE AVE NW STE 100
GRAND RAPIDS MI
49503-6714
US

V. Phone/Fax

Practice location:
  • Phone: 616-916-3711
  • Fax:
Mailing address:
  • Phone: 616-916-3711
  • Fax: 616-825-6015

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberL2285555
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: