Provider Demographics
NPI:1700025152
Name:ROALEEN, KATHRYN J (MA,, L LP,)
Entity Type:Individual
Prefix:MS
First Name:KATHRYN
Middle Name:J
Last Name:ROALEEN
Suffix:
Gender:F
Credentials:MA,, L LP,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5039 10 MILE RD NE
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:MI
Mailing Address - Zip Code:49341-9301
Mailing Address - Country:US
Mailing Address - Phone:616-866-4514
Mailing Address - Fax:
Practice Address - Street 1:5039 10 MILE RD NE
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:MI
Practice Address - Zip Code:49341-9301
Practice Address - Country:US
Practice Address - Phone:616-866-4514
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-09
Last Update Date:2009-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301009417103TC0700X
MI6802018463104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker