Healthcare Provider Details

I. General information

NPI: 1770911257
Provider Name (Legal Business Name): MARK ROGERS LPC,LBSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/22/2013
Last Update Date: 10/22/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7027 MELDRUM RD
IRA MI
48023-2427
US

IV. Provider business mailing address

7027 MELDRUM
FAIR HAVEN MI
48023
US

V. Phone/Fax

Practice location:
  • Phone: 586-725-0560
  • Fax:
Mailing address:
  • Phone: 586-725-0560
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401000566
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6802062229
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: