Healthcare Provider Details

I. General information

NPI: 1003119561
Provider Name (Legal Business Name): ROGER WILLIAM MANELA LMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/06/2010
Last Update Date: 12/06/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40404 VILLAGE WOOD RD
NOVI MI
48375-4561
US

IV. Provider business mailing address

40404 VILLAGE WOOD RD
NOVI MI
48375-4561
US

V. Phone/Fax

Practice location:
  • Phone: 248-474-8960
  • Fax:
Mailing address:
  • Phone: 248-474-8960
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801064714
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: