Provider Demographics
NPI:1922130467
Name:FALL, ROXANNE KAY (PHD, LLP)
Entity Type:Individual
Prefix:DR
First Name:ROXANNE
Middle Name:KAY
Last Name:FALL
Suffix:
Gender:F
Credentials:PHD, LLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:955 E 8TH ST STE 2
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49686-2785
Mailing Address - Country:US
Mailing Address - Phone:231-642-6675
Mailing Address - Fax:231-946-9788
Practice Address - Street 1:955 E. 8TH STREET
Practice Address - Street 2:SUITE 2
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49686-2785
Practice Address - Country:US
Practice Address - Phone:231-946-0299
Practice Address - Fax:231-946-9788
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-11
Last Update Date:2020-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301011930103TC0700X
MI68010698501041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical