MEDICARE: MICHAEL LEROY ROAN MA/CCC-SLP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist

General Provider Information

NPI Number	:	1336752252
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHAEL LEROY ROAN MA/CCC-SLP

Provider Business Mailing Address
First Line	:	36 RAZORBILL LN
Second Line	:
City	:	VALLIANT
State	:	OK
Zip	:	74764-5103
Country	:	US
Telephone Number	:	903-293-7426
Fax Number	:

Provider Business Practice Location Address
First Line	:	2407 W MAIN ST
Second Line	:
City	:	CLARKSVILLE
State	:	TX
Zip	:	75426-3327
Country	:	US
Telephone Number	:	877-364-6571
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/29/2020
Last Update Date	:	08/29/2020

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