Provider Demographics
NPI:1114191822
Name:ROGERS, MICHELLE
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:ROGERS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2813 ROBERT DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:IL
Mailing Address - Zip Code:62236-2671
Mailing Address - Country:US
Mailing Address - Phone:314-471-6798
Mailing Address - Fax:
Practice Address - Street 1:2813 ROBERT DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:IL
Practice Address - Zip Code:62236-2671
Practice Address - Country:US
Practice Address - Phone:314-471-6798
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-15
Last Update Date:2020-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004022311235Z00000X
IL146.07862235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO468342209Medicaid