Healthcare Provider Details

I. General information

NPI: 1972581676
Provider Name (Legal Business Name): AMY MARIE ROCHE MA LLPC NCC
Entity Type: Individual
Gender: Female
Sole Proprietor: X

Provider Other Name: MISS AMY MARIE CLAVIN

II. Dates (important events)

Enumeration Date: 01/04/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12434 12 MILE CATHOLIC SERVICES OF MACOMB, STE 201
WARREN MI
48093
US

IV. Provider business mailing address

17881 BISCAYNE DR
MACOMB MI
48042-2370
US

V. Phone/Fax

Practice location:
  • Phone: 586-416-2300
  • Fax: 586-416-2311
Mailing address:
  • Phone: 586-677-6253
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401009495
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: