Provider Demographics
NPI:1134475452
Name:ROE, MICHAEL (LCSW, LCPC)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:
Last Name:ROE
Suffix:
Gender:M
Credentials:LCSW, LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 RING RD
Mailing Address - Street 2:2454
Mailing Address - City:CALUMET CITY
Mailing Address - State:IL
Mailing Address - Zip Code:60409-7200
Mailing Address - Country:US
Mailing Address - Phone:708-898-8745
Mailing Address - Fax:
Practice Address - Street 1:1200 RING RD
Practice Address - Street 2:2454
Practice Address - City:CALUMET CITY
Practice Address - State:IL
Practice Address - Zip Code:60409-7200
Practice Address - Country:US
Practice Address - Phone:708-898-8745
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-24
Last Update Date:2016-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0165001041C0700X
IL180.007091101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional