Provider Demographics
NPI:1407380991
Name:ROGGOW, TERESA
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:
Last Name:ROGGOW
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 1:201 W FRONT ST
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:MI
Mailing Address - Zip Code:48161-2355
Mailing Address - Country:US
Mailing Address - Phone:734-639-9586
Mailing Address - Fax:
Practice Address - Street 1:201 W FRONT ST
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:MI
Practice Address - Zip Code:48161-2355
Practice Address - Country:US
Practice Address - Phone:734-639-9586
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-12
Last Update Date:2017-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist