Provider Demographics
NPI:1760767479
Name:ROGERS, DENISE (PTA)
Entity Type:Individual
Prefix:
First Name:DENISE
Middle Name:
Last Name:ROGERS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1619 CANTON ST
Mailing Address - Street 2:
Mailing Address - City:ELKHART
Mailing Address - State:IN
Mailing Address - Zip Code:46514-3443
Mailing Address - Country:US
Mailing Address - Phone:574-350-8601
Mailing Address - Fax:
Practice Address - Street 1:1619 CANTON ST
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46514-3443
Practice Address - Country:US
Practice Address - Phone:574-333-7331
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-13
Last Update Date:2014-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06002317A261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy