Healthcare Provider Details

I. General information

NPI: 1730639147
Provider Name (Legal Business Name): MATTHEW ROGERS LMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/10/2016
Last Update Date: 12/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

812 E JOLLY RD
LANSING MI
48910-6825
US

IV. Provider business mailing address

812 E JOLLY RD STE 311
LANSING MI
48910-6825
US

V. Phone/Fax

Practice location:
  • Phone: 517-346-8318
  • Fax: 517-346-8420
Mailing address:
  • Phone: 517-346-8200
  • Fax: 517-346-8291

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801100062
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: