Healthcare Provider Details

I. General information

NPI: 1457015018
Provider Name (Legal Business Name): BRYAN CHRISTOPHER ROACH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/28/2021
Last Update Date: 10/28/2021
Certification Date: 10/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

43825 MICHIGAN AVE
CANTON MI
48188-2551
US

IV. Provider business mailing address

37579 N DIANNE LN
NEW BOSTON MI
48164-8005
US

V. Phone/Fax

Practice location:
  • Phone: 734-397-3088
  • Fax:
Mailing address:
  • Phone: 734-548-5185
  • Fax:

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: