Healthcare Provider Details

I. General information

NPI: 1386843274
Provider Name (Legal Business Name): ROGER LEE MACE D.MIN.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/12/2007
Last Update Date: 01/11/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13491 PORT REPUBLIC RD
GROTTOES VA
24441-5216
US

IV. Provider business mailing address

13491 PORT REPUBLIC RD
GROTTOES VA
24441-5216
US

V. Phone/Fax

Practice location:
  • Phone: 540-249-3780
  • Fax: 540-249-3780
Mailing address:
  • Phone: 540-249-3780
  • Fax: 540-249-3780

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0717000360
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: