1649314956 NPI number — MRS. PHYLLIS RUTH ROELOFS

Table of content: MRS. PHYLLIS RUTH ROELOFS (NPI 1649314956)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649314956 NPI number — MRS. PHYLLIS RUTH ROELOFS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROELOFS
Provider First Name:
PHYLLIS
Provider Middle Name:
RUTH
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
ROELOFS
Provider Other First Name:
PHYLLIS
Provider Other Middle Name:
RUTH
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
LCSW
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1649314956
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/13/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4426 WISTERIA CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WARREN
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48092-6116
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-459-2002
Provider Business Mailing Address Fax Number:
586-574-0389

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4426 WISTERIA CT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WARREN
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48092-6116
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-459-2002
Provider Business Practice Location Address Fax Number:
586-574-0389
Provider Enumeration Date:
02/19/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  6801060243 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 8009078570 . This is a "BLUECROSSBLUESHIELD" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 040252 . This is a "VALUEOPTIONS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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