Provider Demographics
NPI:1336752252
Name:ROAN, MICHAEL LEROY (MA/CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:LEROY
Last Name:ROAN
Suffix:
Gender:M
Credentials:MA/CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36 RAZORBILL LN
Mailing Address - Street 2:
Mailing Address - City:VALLIANT
Mailing Address - State:OK
Mailing Address - Zip Code:74764-5103
Mailing Address - Country:US
Mailing Address - Phone:903-293-7426
Mailing Address - Fax:
Practice Address - Street 1:2407 W MAIN ST
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TX
Practice Address - Zip Code:75426-3327
Practice Address - Country:US
Practice Address - Phone:877-364-6571
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-29
Last Update Date:2020-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist