Healthcare Provider Details

I. General information

NPI: 1356898225
Provider Name (Legal Business Name): ROSHELLE WOODS BA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/08/2016
Last Update Date: 09/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20724 EUREKA RD
TAYLOR MI
48180-5313
US

IV. Provider business mailing address

4951 S HAGGERTY RD LOT 41
CANTON MI
48188-2858
US

V. Phone/Fax

Practice location:
  • Phone: 734-759-0510
  • Fax:
Mailing address:
  • Phone: 734-787-1401
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: