Basic Information
| Provider Information | |||||||||
| NPI: | 1396079448 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROGERS | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DPT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | TARR | ||||||||
| OtherFirstName: | KELLY | ||||||||
| OtherMiddleName: | MARIE | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1205 YORK RD | ||||||||
| Address2: | STE 19 | ||||||||
| City: | LUTHERVILLE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210936210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4102969195 | ||||||||
| FaxNumber: | 4102969197 | ||||||||
| Practice Location | |||||||||
| Address1: | 1205 YORK RD | ||||||||
| Address2: | STE 19 | ||||||||
| City: | LUTHERVILLE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210936210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4102969195 | ||||||||
| FaxNumber: | 4102969197 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/22/2009 | ||||||||
| LastUpdateDate: | 05/04/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/04/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 22994 | MD | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.