Provider Demographics
NPI:1386843274
Name:MACE, ROGER LEE (DMIN)
Entity Type:Individual
Prefix:DR
First Name:ROGER
Middle Name:LEE
Last Name:MACE
Suffix:
Gender:M
Credentials:DMIN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13491 PORT REPUBLIC RD
Mailing Address - Street 2:
Mailing Address - City:GROTTOES
Mailing Address - State:VA
Mailing Address - Zip Code:24441-5216
Mailing Address - Country:US
Mailing Address - Phone:540-249-3780
Mailing Address - Fax:540-249-3780
Practice Address - Street 1:13491 PORT REPUBLIC RD
Practice Address - Street 2:
Practice Address - City:GROTTOES
Practice Address - State:VA
Practice Address - Zip Code:24441-5216
Practice Address - Country:US
Practice Address - Phone:540-249-3780
Practice Address - Fax:540-249-3780
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-12
Last Update Date:2009-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0717000360101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health