Provider Demographics
NPI:1902446859
Name:ROGERS, NICOLE (LMT)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:ROGERS
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21155 MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:MATTESON
Mailing Address - State:IL
Mailing Address - Zip Code:60443-2529
Mailing Address - Country:US
Mailing Address - Phone:708-927-3400
Mailing Address - Fax:
Practice Address - Street 1:19815 GOVERNORS HWY STE 1A
Practice Address - Street 2:
Practice Address - City:FLOSSMOOR
Practice Address - State:IL
Practice Address - Zip Code:60422-4321
Practice Address - Country:US
Practice Address - Phone:708-927-3400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-08
Last Update Date:2020-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
376J00000X
IL227020807225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No376J00000XNursing Service Related ProvidersHomemaker