Provider Demographics
NPI:1770911257
Name:ROGERS, MARK (LPC,LBSW)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:
Last Name:ROGERS
Suffix:
Gender:M
Credentials:LPC,LBSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7027 MELDRUM
Mailing Address - Street 2:
Mailing Address - City:FAIR HAVEN
Mailing Address - State:MI
Mailing Address - Zip Code:48023
Mailing Address - Country:US
Mailing Address - Phone:586-725-0560
Mailing Address - Fax:
Practice Address - Street 1:7027 MELDRUM RD
Practice Address - Street 2:
Practice Address - City:IRA
Practice Address - State:MI
Practice Address - Zip Code:48023-2427
Practice Address - Country:US
Practice Address - Phone:586-725-0560
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-22
Last Update Date:2013-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401000566101YP2500X
MI68020622291041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MISTOOLMANLPC4Medicaid
MISTOOLMANLPC4Medicare PIN