Provider Demographics
NPI:1932407319
Name:ROEDER, MICHELE ANNE (LCPC)
Entity Type:Individual
Prefix:MS
First Name:MICHELE
Middle Name:ANNE
Last Name:ROEDER
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:MICHELE
Other - Middle Name:ANNE
Other - Last Name:STEPHENS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCPC
Mailing Address - Street 1:2891 W GEMSTONE DR
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83646-1195
Mailing Address - Country:US
Mailing Address - Phone:208-936-5111
Mailing Address - Fax:
Practice Address - Street 1:9514 W FAIRVIEW AVE STE 100
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-0614
Practice Address - Country:US
Practice Address - Phone:208-936-5111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-08
Last Update Date:2023-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCPC-3375101YP2500X, 101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional