Provider Demographics
NPI:1730428699
Name:CASEY, ROGER JOHN JR (ATC)
Entity type:Individual
Prefix:
First Name:ROGER
Middle Name:JOHN
Last Name:CASEY
Suffix:JR
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12280 228TH ST N
Mailing Address - Street 2:
Mailing Address - City:SCANDIA
Mailing Address - State:MN
Mailing Address - Zip Code:55073-9467
Mailing Address - Country:US
Mailing Address - Phone:651-399-8497
Mailing Address - Fax:
Practice Address - Street 1:12280 228TH ST N
Practice Address - Street 2:
Practice Address - City:SCANDIA
Practice Address - State:MN
Practice Address - Zip Code:55073-9467
Practice Address - Country:US
Practice Address - Phone:651-399-8497
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-12
Last Update Date:2016-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN11092255A2300X
MN304448101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer