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General NPI Number Information
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NPI Number | 1609412675
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Entity Type | Individual
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Provider Name | ETHAN ROGERS OTR/L
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Gender | Male
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Dates
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Enumeration Date | 11/25/2019
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Last Update Date | 05/03/2021
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Provider Practice Location Address
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Address Line | 3555 COPPER RIVER AVE SW
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City | WYOMING
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State | MI
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Zip | 49418-9791
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Country | US
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Telephone | 616-369-7448
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Fax |
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Provider Business Mailing Address
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Address Line | 2555 FOX RUN RD SW APT 10
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City | WYOMING
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State | MI
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Zip | 49519-5210
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 106S00000X
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Taxonomy Name | Behavior Technician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 225X00000X
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Taxonomy Name | Occupational Therapist
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License Number |
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License Number State |
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