Provider Demographics
NPI:1881741700
Name:ROELOFS-HAUGHN, SUSAN KAY (LMSW, ACSW)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:KAY
Last Name:ROELOFS-HAUGHN
Suffix:
Gender:F
Credentials:LMSW, ACSW
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:KAY
Other - Last Name:HAUGHN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LMSW, ACSW
Mailing Address - Street 1:402 S UNION ST
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-5754
Mailing Address - Country:US
Mailing Address - Phone:231-342-1002
Mailing Address - Fax:231-947-4311
Practice Address - Street 1:402 S UNION ST
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-5754
Practice Address - Country:US
Practice Address - Phone:231-342-1002
Practice Address - Fax:231-947-4311
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010163821041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI03923291Medicaid
MI03923291Medicaid