Healthcare Provider Details

I. General information

NPI: 1659800878
Provider Name (Legal Business Name): WANDA ANN ROGERS MA, EDD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: WANDA ANN BANKS

II. Dates (important events)

Enumeration Date: 06/10/2017
Last Update Date: 06/10/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1028 CASS AVE SE
GRAND RAPIDS MI
49507-1120
US

IV. Provider business mailing address

1028 CASS AVE SE
GRAND RAPIDS MI
49507-1120
US

V. Phone/Fax

Practice location:
  • Phone: 616-241-3396
  • Fax:
Mailing address:
  • Phone: 616-241-3396
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401011542
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: