Provider Demographics
NPI:1407095201
Name:ROGERS, KIM
Entity Type:Individual
Prefix:
First Name:KIM
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 1:925 WHITMORE RD APT 202
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48203-4103
Mailing Address - Country:US
Mailing Address - Phone:313-320-2349
Mailing Address - Fax:
Practice Address - Street 1:707 W MILWAUKEE ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202-2943
Practice Address - Country:US
Practice Address - Phone:313-344-9099
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-18
Last Update Date:2021-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI823010324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility