Healthcare Provider Details

I. General information

NPI: 1972106193
Provider Name (Legal Business Name): ROXANE ALISON MCCARRON MA, LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/19/2020
Last Update Date: 11/19/2020
Certification Date: 11/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 MONROE AVE NW STE 400
GRAND RAPIDS MI
49503-2293
US

IV. Provider business mailing address

3907 BRUCE DR SW
GRANDVILLE MI
49418-2433
US

V. Phone/Fax

Practice location:
  • Phone: 616-560-6502
  • Fax:
Mailing address:
  • Phone: 616-560-6502
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401005441
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: