Provider Demographics
NPI:1215582606
Name:ROGERS, COLLEEN KATY (MSP, MPA)
Entity Type:Individual
Prefix:MRS
First Name:COLLEEN
Middle Name:KATY
Last Name:ROGERS
Suffix:
Gender:F
Credentials:MSP, MPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:640 E 152ND ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:IL
Mailing Address - Zip Code:60426-2454
Mailing Address - Country:US
Mailing Address - Phone:708-271-3384
Mailing Address - Fax:
Practice Address - Street 1:640 E 152ND ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:IL
Practice Address - Zip Code:60426-2454
Practice Address - Country:US
Practice Address - Phone:708-271-3384
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-03
Last Update Date:2019-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL331622717001Medicaid