Healthcare Provider Details

I. General information

NPI: 1770394181
Provider Name (Legal Business Name): KALEB ROCHA CTRS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/15/2025
Last Update Date: 01/15/2025
Certification Date: 01/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2800 LIVERNOIS RD
TROY MI
48083-1215
US

IV. Provider business mailing address

35545 CLINTON ST
WAYNE MI
48184-2151
US

V. Phone/Fax

Practice location:
  • Phone: 248-615-2090
  • Fax:
Mailing address:
  • Phone: 419-906-9933
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225800000X
TaxonomyRecreation Therapist
License Number81326
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: