Provider Demographics
NPI:1144469685
Name:ROGERS, GLENDA RENEE
Entity type:Individual
Prefix:
First Name:GLENDA
Middle Name:RENEE
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 1:5131 N WOLCOTT AVE
Mailing Address - Street 2:APT 2
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-2612
Mailing Address - Country:US
Mailing Address - Phone:847-676-4447
Mailing Address - Fax:847-676-4450
Practice Address - Street 1:9239 GROSS POINT RD
Practice Address - Street 2:SUITE 300
Practice Address - City:SKOKIE
Practice Address - State:IL
Practice Address - Zip Code:60077-1389
Practice Address - Country:US
Practice Address - Phone:847-676-4447
Practice Address - Fax:847-676-4450
Is Sole Proprietor?:No
Enumeration Date:2009-02-06
Last Update Date:2009-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL166.000749106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist