Provider Demographics
NPI:1891376620
Name:MARKS, ROGER ALLEN
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:ALLEN
Last Name:MARKS
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 1:911 STACEY BURK DR
Mailing Address - Street 2:
Mailing Address - City:FLORA
Mailing Address - State:IL
Mailing Address - Zip Code:62839-3241
Mailing Address - Country:US
Mailing Address - Phone:618-662-6621
Mailing Address - Fax:
Practice Address - Street 1:911 STACEY BURK DR
Practice Address - Street 2:
Practice Address - City:FLORA
Practice Address - State:IL
Practice Address - Zip Code:62839-3241
Practice Address - Country:US
Practice Address - Phone:618-662-6621
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-14
Last Update Date:2021-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180-003309101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional