Provider Demographics
NPI:1619218195
Name:ROGERS, KRISTEN NICOLE (LPC)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:NICOLE
Last Name:ROGERS
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:648 MONROE AVE NW STE 100
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-6714
Mailing Address - Country:US
Mailing Address - Phone:616-916-3711
Mailing Address - Fax:616-825-6015
Practice Address - Street 1:648 MONROE AVE NW
Practice Address - Street 2:SUITE 216
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-1452
Practice Address - Country:US
Practice Address - Phone:616-916-3711
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-08
Last Update Date:2019-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIL2285555101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional