Healthcare Provider Details

I. General information

NPI: 1104159532
Provider Name (Legal Business Name): ROXANNE HAYNES LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/17/2009
Last Update Date: 03/26/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6549 TOWN CENTER DR SUITE A
CLARKSTON MI
48346-4824
US

IV. Provider business mailing address

49061 SOUTH INTERSTATE 94 APT 106
BELLEVILLE MI
48111
US

V. Phone/Fax

Practice location:
  • Phone: 248-620-6400
  • Fax: 248-620-6405
Mailing address:
  • Phone: 470-255-7723
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801088453
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: