Healthcare Provider Details

I. General information

NPI: 1043123748
Provider Name (Legal Business Name): KERRY ROGERS
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/24/2026
Last Update Date: 09/24/2026
Certification Date: 09/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5816 W US HIGHWAY 10 STE 2B
LUDINGTON MI
49431-2450
US

IV. Provider business mailing address

625 KENMOOR AVE SE
GRAND RAPIDS MI
49546-2395
US

V. Phone/Fax

Practice location:
  • Phone: 231-519-8300
  • Fax:
Mailing address:
  • Phone: 231-519-8300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: