Provider Demographics
NPI:1639352669
Name:ROGERS, MARTHA J (PHD)
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:J
Last Name:ROGERS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:416 XENIA AVE
Mailing Address - Street 2:
Mailing Address - City:YELLOW SPRINGS
Mailing Address - State:OH
Mailing Address - Zip Code:45387-1836
Mailing Address - Country:US
Mailing Address - Phone:937-767-9171
Mailing Address - Fax:937-767-9175
Practice Address - Street 1:416 XENIA AVE
Practice Address - Street 2:
Practice Address - City:YELLOW SPRINGS
Practice Address - State:OH
Practice Address - Zip Code:45387-1836
Practice Address - Country:US
Practice Address - Phone:937-767-9171
Practice Address - Fax:937-767-9175
Is Sole Proprietor?:No
Enumeration Date:2007-12-13
Last Update Date:2010-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH6404103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical