Healthcare Provider Details

I. General information

NPI: 1528035599
Provider Name (Legal Business Name): ROBERT DEFORREST ROGGENBACH M.S.W.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/08/2006
Last Update Date: 01/11/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12600 E 40 HWY SUITE 101
INDEPENDENCE MO
64055-5955
US

IV. Provider business mailing address

12600 E 40 HWY SUITE 101
INDEPENDENCE MO
64055-5955
US

V. Phone/Fax

Practice location:
  • Phone: 816-350-3333
  • Fax: 816-478-8888
Mailing address:
  • Phone: 816-350-3333
  • Fax: 816-478-8888

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW 000177
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: