Provider Demographics
NPI:1477857654
Name:ROGERS, MARIE GERALYN
Entity Type:Individual
Prefix:
First Name:MARIE
Middle Name:GERALYN
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 1:606 LOMA CT
Mailing Address - Street 2:
Mailing Address - City:SUISUN CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94585-3027
Mailing Address - Country:US
Mailing Address - Phone:707-208-6479
Mailing Address - Fax:
Practice Address - Street 1:1735 ENTERPRISE DR BLDG 1
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94533-6822
Practice Address - Country:US
Practice Address - Phone:707-425-1799
Practice Address - Fax:707-425-1081
Is Sole Proprietor?:No
Enumeration Date:2011-01-03
Last Update Date:2011-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YM0800X, 103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst