Provider Demographics
NPI:1629938147
Name:ROGGOW, TYLER
Entity type:Individual
Prefix:
First Name:TYLER
Middle Name:
Last Name:ROGGOW
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:921 BROADUS ST
Mailing Address - Street 2:
Mailing Address - City:STURGIS
Mailing Address - State:MI
Mailing Address - Zip Code:49091-2403
Mailing Address - Country:US
Mailing Address - Phone:833-624-6385
Mailing Address - Fax:855-314-0085
Practice Address - Street 1:921 BROADUS ST
Practice Address - Street 2:
Practice Address - City:STURGIS
Practice Address - State:MI
Practice Address - Zip Code:49091-2403
Practice Address - Country:US
Practice Address - Phone:833-624-6385
Practice Address - Fax:855-314-0085
Is Sole Proprietor?:No
Enumeration Date:2025-11-17
Last Update Date:2025-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst