Healthcare Provider Details

I. General information

NPI: 1164842936
Provider Name (Legal Business Name): ROXANN KACOS LLMSW CADC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/21/2014
Last Update Date: 02/27/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3300 36TH ST SE
GRAND RAPIDS MI
49512-2810
US

IV. Provider business mailing address

3300 36TH ST SE
GRAND RAPIDS MI
49512-2810
US

V. Phone/Fax

Practice location:
  • Phone: 616-942-7294
  • Fax: 616-942-9548
Mailing address:
  • Phone: 616-942-7294
  • Fax: 616-942-9548

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801095912
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: