MEDICARE: MR. ROY CHARLES HEEREN LMSW, ACSW

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	1041C0700X	Clinical Social Worker	6801020676	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	800B800100	OTHER	MI	BLUE CROSS

General Provider Information

NPI Number	:	1548317985
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ROY CHARLES HEEREN LMSW, ACSW

Provider Business Mailing Address
First Line	:	12935 S WEST BAY SHORE DR STE 330
Second Line	:
City	:	TRAVERSE CITY
State	:	MI
Zip	:	49684-6291
Country	:	US
Telephone Number	:	231-933-4661
Fax Number	:	231-933-4661

Provider Business Practice Location Address
First Line	:	12935 S WEST BAY SHORE DR STE 330
Second Line	:
City	:	TRAVERSE CITY
State	:	MI
Zip	:	49684-6291
Country	:	US
Telephone Number	:	231-933-4661
Fax Number	:	231-933-4661

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

Provider Enumeration Date	:	01/05/2007
Last Update Date	:	05/13/2019

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