Healthcare Provider Details

I. General information

NPI: 1477898385
Provider Name (Legal Business Name): STEPHEN C ROEGGE LMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/04/2012
Last Update Date: 01/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2020 RAYBROOK SE SUITE 306
GRAND RAPIDS MI
49546
US

IV. Provider business mailing address

31 LOWELL NE
GRAND RAPIDS MI
49503
US

V. Phone/Fax

Practice location:
  • Phone: 616-450-0656
  • Fax:
Mailing address:
  • Phone: 616-450-0656
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801087215
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: