Provider Demographics
NPI:1376084046
Name:ROLDAN, MARY (LPC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:ROLDAN
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1825 RIVERSIDE DR
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54301-2316
Mailing Address - Country:US
Mailing Address - Phone:920-272-8234
Mailing Address - Fax:
Practice Address - Street 1:1475 OPPORTUNITY WAY
Practice Address - Street 2:
Practice Address - City:MENASHA
Practice Address - State:WI
Practice Address - Zip Code:54952-1293
Practice Address - Country:US
Practice Address - Phone:920-734-2601
Practice Address - Fax:651-323-2648
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-15
Last Update Date:2024-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX74395101YP2500X
WI10239-125101YP2500X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional