Provider Demographics
NPI:1447774757
Name:ROGERS, LISA ANN
Entity Type:Individual
Prefix:MISS
First Name:LISA
Middle Name:ANN
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 1:2101 LEXINGTON DR APT 3
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62704-5688
Mailing Address - Country:US
Mailing Address - Phone:217-725-4313
Mailing Address - Fax:
Practice Address - Street 1:2101 LEXINGTON DR
Practice Address - Street 2:APT 3
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62704
Practice Address - Country:US
Practice Address - Phone:217-725-4313
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-28
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist