Healthcare Provider Details

I. General information

NPI: 1841272960
Provider Name (Legal Business Name): STEPHANIE LYNN ROFFEY LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: X

Provider Other Name: STEPHANIE LYNN RUSKIN LCSW

II. Dates (important events)

Enumeration Date: 11/15/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19501 W CATAWBA AVE SUITE 15 MAILBOX 22
CORNELIUS NC
28031-4017
US

IV. Provider business mailing address

18701 THE COMMONS BLVD
CORNELIUS NC
28031-7070
US

V. Phone/Fax

Practice location:
  • Phone: 704-516-0971
  • Fax:
Mailing address:
  • Phone: 704-516-0971
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberC003522
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: