Healthcare Provider Details

I. General information

NPI: 1457687402
Provider Name (Legal Business Name): THOMAS M ROE LCAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/27/2009
Last Update Date: 04/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2600 OAKLAND AVE
ELKHART IN
46517-1533
US

IV. Provider business mailing address

PO BOX 809
GOSHEN IN
46527-0809
US

V. Phone/Fax

Practice location:
  • Phone: 574-533-1234
  • Fax: 574-537-2652
Mailing address:
  • Phone: 574-533-1234
  • Fax: 574-537-2652

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: