Provider Demographics
NPI:1649314956
Name:ROELOFS, PHYLLIS RUTH
Entity type:Individual
Prefix:MRS
First Name:PHYLLIS
Middle Name:RUTH
Last Name:ROELOFS
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:PHYLLIS
Other - Middle Name:RUTH
Other - Last Name:ROELOFS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:4426 WISTERIA CT
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48092-6116
Mailing Address - Country:US
Mailing Address - Phone:248-459-2002
Mailing Address - Fax:586-574-0389
Practice Address - Street 1:4426 WISTERIA CT
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48092-6116
Practice Address - Country:US
Practice Address - Phone:248-459-2002
Practice Address - Fax:586-574-0389
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-19
Last Update Date:2014-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010602431041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI8009078570OtherBLUECROSSBLUESHIELD
MI040252OtherVALUEOPTIONS
MIOF37006036Medicare ID - Type Unspecified