Provider Demographics
NPI:1457548588
Name:ROLL, MARJORIE KAY (LSW)
Entity Type:Individual
Prefix:
First Name:MARJORIE
Middle Name:KAY
Last Name:ROLL
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3416 COLUMBUS AVE
Mailing Address - Street 2:
Mailing Address - City:SANDUSKY
Mailing Address - State:OH
Mailing Address - Zip Code:44870-5557
Mailing Address - Country:US
Mailing Address - Phone:419-735-0625
Mailing Address - Fax:
Practice Address - Street 1:416 COLUMBUS AVE
Practice Address - Street 2:
Practice Address - City:SANDUSKY
Practice Address - State:OH
Practice Address - Zip Code:44870-2753
Practice Address - Country:US
Practice Address - Phone:419-627-1647
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-02
Last Update Date:2017-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS 0030925104100000X
OHI 17000021041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker