Provider Demographics
NPI:1548369283
Name:ROGERS, SHELLEY K (PTA)
Entity type:Individual
Prefix:MRS
First Name:SHELLEY
Middle Name:K
Last Name:ROGERS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16622 PLANK RD
Mailing Address - Street 2:
Mailing Address - City:UNION GROVE
Mailing Address - State:WI
Mailing Address - Zip Code:53182-9697
Mailing Address - Country:US
Mailing Address - Phone:262-878-5179
Mailing Address - Fax:
Practice Address - Street 1:7201 GREEN BAY RD
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53142-3522
Practice Address - Country:US
Practice Address - Phone:262-694-3977
Practice Address - Fax:262-694-5648
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI710-019225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant