Provider Demographics
NPI:1134675630
Name:ROGERS, GINA MARIE (LMT, CMLDT)
Entity type:Individual
Prefix:
First Name:GINA
Middle Name:MARIE
Last Name:ROGERS
Suffix:
Gender:F
Credentials:LMT, CMLDT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2035 HOGBACK RD STE 207
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48105-9488
Mailing Address - Country:US
Mailing Address - Phone:734-252-6278
Mailing Address - Fax:
Practice Address - Street 1:2035 HOGBACK RD STE 207
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48105-9488
Practice Address - Country:US
Practice Address - Phone:734-252-6278
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-25
Last Update Date:2020-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7501009000225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist