Provider Demographics
NPI:1831616523
Name:ROGERS, CANDACE
Entity type:Individual
Prefix:
First Name:CANDACE
Middle Name:
Last Name:ROGERS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:388 DALLAS 119
Mailing Address - Street 2:
Mailing Address - City:FORDYCE
Mailing Address - State:AR
Mailing Address - Zip Code:71742-8609
Mailing Address - Country:US
Mailing Address - Phone:870-352-2573
Mailing Address - Fax:
Practice Address - Street 1:1807 W MOLINE ST
Practice Address - Street 2:
Practice Address - City:MALVERN
Practice Address - State:AR
Practice Address - Zip Code:72104-2645
Practice Address - Country:US
Practice Address - Phone:501-467-3166
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-24
Last Update Date:2017-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant