Provider Demographics
NPI:1043703168
Name:ROESSER, GREGORY S
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:S
Last Name:ROESSER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7540 NEW WEST RD
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43617-4200
Mailing Address - Country:US
Mailing Address - Phone:419-901-3176
Mailing Address - Fax:
Practice Address - Street 1:7540 NEW WEST RD
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43617-4200
Practice Address - Country:US
Practice Address - Phone:419-901-3176
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-13
Last Update Date:2018-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH100225101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH81-3522511Medicaid