Provider Demographics
NPI:1861684599
Name:ROGERS, LARRY GLEN (ACHT)
Entity Type:Individual
Prefix:MR
First Name:LARRY
Middle Name:GLEN
Last Name:ROGERS
Suffix:
Gender:M
Credentials:ACHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1320 SW HALL ST
Mailing Address - Street 2:#203
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97201-3261
Mailing Address - Country:US
Mailing Address - Phone:503-781-6542
Mailing Address - Fax:
Practice Address - Street 1:1320 SW HALL ST
Practice Address - Street 2:#203
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97201-3261
Practice Address - Country:US
Practice Address - Phone:503-781-6542
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-16
Last Update Date:2007-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor