Provider Demographics
NPI:1518367911
Name:RODGERS, COLLEEN ANN (COTA)
Entity Type:Individual
Prefix:MRS
First Name:COLLEEN
Middle Name:ANN
Last Name:RODGERS
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5202 HEATHER LN
Mailing Address - Street 2:
Mailing Address - City:JOHNSBURG
Mailing Address - State:IL
Mailing Address - Zip Code:60051-5215
Mailing Address - Country:US
Mailing Address - Phone:815-245-7986
Mailing Address - Fax:
Practice Address - Street 1:390 E CONGRESS PKWY
Practice Address - Street 2:
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60014-6202
Practice Address - Country:US
Practice Address - Phone:815-477-4788
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-04
Last Update Date:2014-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL057.004031224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant