Provider Demographics
NPI:1659800878
Name:ROGERS, WANDA ANN (MA, EDD)
Entity Type:Individual
Prefix:DR
First Name:WANDA
Middle Name:ANN
Last Name:ROGERS
Suffix:
Gender:F
Credentials:MA, EDD
Other - Prefix:
Other - First Name:WANDA
Other - Middle Name:ANN
Other - Last Name:BANKS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1028 CASS AVE SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49507-1120
Mailing Address - Country:US
Mailing Address - Phone:616-241-3396
Mailing Address - Fax:
Practice Address - Street 1:1028 CASS AVE SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49507-1120
Practice Address - Country:US
Practice Address - Phone:616-241-3396
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-10
Last Update Date:2017-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401011542101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty