Provider Demographics
NPI:1508287129
Name:ROGERS, ROBERT MICHAEL (MS, LCPC, NCC)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:MICHAEL
Last Name:ROGERS
Suffix:
Gender:M
Credentials:MS, LCPC, NCC
Other - Prefix:MR
Other - First Name:BOB
Other - Middle Name:MICHAEL
Other - Last Name:ROGERS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MS, LCPC, NCC
Mailing Address - Street 1:12 RUTHERFORD CT
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61705-6518
Mailing Address - Country:US
Mailing Address - Phone:309-533-9578
Mailing Address - Fax:
Practice Address - Street 1:12 RUTHERFORD CT
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61705-6518
Practice Address - Country:US
Practice Address - Phone:309-533-9578
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-27
Last Update Date:2013-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180-000642101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional