Healthcare Provider Details

I. General information

NPI: 1942185111
Provider Name (Legal Business Name): COURTNEY DEANN ROGAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/07/2025
Last Update Date: 08/07/2025
Certification Date: 07/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1430 OLIVE ST
SAINT LOUIS MO
63103-2360
US

IV. Provider business mailing address

1430 OLIVE ST
SAINT LOUIS MO
63103-2360
US

V. Phone/Fax

Practice location:
  • Phone: 314-645-6840
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number2025033773
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: