Provider Demographics
NPI:1508185281
Name:ROUMELL, TRACY L (RD)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:L
Last Name:ROUMELL
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:TRACY
Other - Middle Name:L
Other - Last Name:SHERMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:1665 WAMPLERS LAKE RD
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:MI
Mailing Address - Zip Code:49230-9571
Mailing Address - Country:US
Mailing Address - Phone:517-262-6186
Mailing Address - Fax:
Practice Address - Street 1:1665 WAMPLERS LAKE RD
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:MI
Practice Address - Zip Code:49230-9571
Practice Address - Country:US
Practice Address - Phone:517-262-6186
Practice Address - Fax:866-596-3099
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-20
Last Update Date:2013-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI801884133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered