Healthcare Provider Details

I. General information

NPI: 1518457100
Provider Name (Legal Business Name): ROXANNE BEATRICE AFFHOLTER LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2018
Last Update Date: 12/30/2024
Certification Date: 12/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 SHELDON AVE SE FL 2
GRAND RAPIDS MI
49503-4224
US

IV. Provider business mailing address

100 MICHIGAN ST NE # MC845
GRAND RAPIDS MI
49503-2560
US

V. Phone/Fax

Practice location:
  • Phone: 616-447-5820
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801102510
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: