Healthcare Provider Details

I. General information

NPI: 1801702402
Provider Name (Legal Business Name): GWENDOLYN ROGERS, LAC P-LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/22/2026
Last Update Date: 08/22/2026
Certification Date: 08/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31 ADAMS AVE STE 4
ENDICOTT NY
13760-5734
US

IV. Provider business mailing address

1 JOHN ST
ITHACA NY
14850-6350
US

V. Phone/Fax

Practice location:
  • Phone: 607-729-0591
  • Fax:
Mailing address:
  • Phone: 503-975-3256
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: GWENDOLYN ROGERS
Title or Position: OWNER/PRACTITIONER
Credential: ND, LAC
Phone: 503-975-3256