MEDICARE: RANDI LEE ROGERS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1891364741
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RANDI LEE ROGERS

Provider Business Mailing Address
First Line	:	2291 W MARCH LN STE C101
Second Line	:
City	:	STOCKTON
State	:	CA
Zip	:	95207-6669
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2230 RINGWOOD AVE
Second Line	:
City	:	STOCKTON
State	:	CA
Zip	:	95210-1641
Country	:	US
Telephone Number	:	209-922-5727
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/23/2021
Last Update Date	:	06/23/2021

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Directions to “ RANDI LEE ROGERS ” Practice Location

Language	Start Address	Practice Location

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