Provider Demographics
NPI:1053920330
Name:ROGGENBAUM, LAURA (MA)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:ROGGENBAUM
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5108 JEWELL TER
Mailing Address - Street 2:
Mailing Address - City:PALM HARBOR
Mailing Address - State:FL
Mailing Address - Zip Code:34685-2696
Mailing Address - Country:US
Mailing Address - Phone:248-933-0154
Mailing Address - Fax:
Practice Address - Street 1:1720 E 120TH ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90059-3052
Practice Address - Country:US
Practice Address - Phone:310-668-4272
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-23
Last Update Date:2020-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program