Provider Demographics
NPI:1801588546
Name:ROGERS, CANDY JO (COTAIL)
Entity type:Individual
Prefix:MRS
First Name:CANDY
Middle Name:JO
Last Name:ROGERS
Suffix:
Gender:F
Credentials:COTAIL
Other - Prefix:
Other - First Name:CANDY
Other - Middle Name:JO
Other - Last Name:HARRELSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:COTAIL
Mailing Address - Street 1:14041 N LINK LN
Mailing Address - Street 2:
Mailing Address - City:MT VERNON
Mailing Address - State:IL
Mailing Address - Zip Code:62864
Mailing Address - Country:US
Mailing Address - Phone:618-841-9110
Mailing Address - Fax:
Practice Address - Street 1:14041 N LINK LN
Practice Address - Street 2:
Practice Address - City:MT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864
Practice Address - Country:US
Practice Address - Phone:618-841-9110
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-22
Last Update Date:2025-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL057002443224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant