Provider Demographics
NPI:1255828976
Name:ROGERS, MADELINE CHRISTINE (BS)
Entity Type:Individual
Prefix:
First Name:MADELINE
Middle Name:CHRISTINE
Last Name:ROGERS
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19800 VILLAGE OFFICE CT. SUITE 104
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97702
Mailing Address - Country:US
Mailing Address - Phone:541-306-3483
Mailing Address - Fax:541-639-8909
Practice Address - Street 1:1170 PEARL ST
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-3541
Practice Address - Country:US
Practice Address - Phone:541-743-4340
Practice Address - Fax:541-743-4369
Is Sole Proprietor?:No
Enumeration Date:2018-04-18
Last Update Date:2020-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORABA-IN-10204626106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORABA-IN-10204626OtherSTATE REGISTRATION