Healthcare Provider Details

I. General information

NPI: 1720958630
Provider Name (Legal Business Name): LILLIAN ROFFERS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/06/2025
Last Update Date: 11/06/2025
Certification Date: 11/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1141 W MAIN AVE
DE PERE WI
54115-1695
US

IV. Provider business mailing address

6225 SMITH AVE STE 1001A
BALTIMORE MD
21209-3626
US

V. Phone/Fax

Practice location:
  • Phone: 920-338-1610
  • Fax: 920-338-1616
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1465-140
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: