Provider Demographics
NPI:1790515906
Name:ROGGENBUCK, KACIE CATHRYN (MA, TLLP)
Entity type:Individual
Prefix:
First Name:KACIE
Middle Name:CATHRYN
Last Name:ROGGENBUCK
Suffix:
Gender:F
Credentials:MA, TLLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42681 PRINCE DR
Mailing Address - Street 2:
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48313-2465
Mailing Address - Country:US
Mailing Address - Phone:989-671-7906
Mailing Address - Fax:
Practice Address - Street 1:1760 S TELEGRAPH RD STE 103&240
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD HILLS
Practice Address - State:MI
Practice Address - Zip Code:48302-0180
Practice Address - Country:US
Practice Address - Phone:248-256-5209
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-02
Last Update Date:2024-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist