MEDICARE: JUDITH ROES HAMMERLE, PH.D., LLC

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	103TC0700X	Clinical Psychologist	6301002085	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	D64517	OTHER	MI	BLUE CROSS BLUE SHIELD OF MICHIGAN
2	03951	OTHER	MI	PARAMOUNT HEALTH CARE

General Provider Information

NPI Number	:	1770714891
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JUDITH ROES HAMMERLE, PH.D., LLC

Provider Business Mailing Address
First Line	:	1183 GLENDALE AVE
Second Line	:
City	:	ADRIAN
State	:	MI
Zip	:	49221-1306
Country	:	US
Telephone Number	:	517-260-1762
Fax Number	:	517-265-2853

Provider Business Practice Location Address
First Line	:	1183 GLENDALE AVE
Second Line	:
City	:	ADRIAN
State	:	MI
Zip	:	49221-1306
Country	:	US
Telephone Number	:	517-260-1762
Fax Number	:	517-265-2853

Authorized Official
Title or Position	:	PSYCHOLOGIST
Name	:	JUDITH ROES HAMMERLE
Credential	:	PH.D.
Telephone Number	:	517-260-1762

Provider Enumeration Date	:	08/06/2009
Last Update Date	:	04/21/2014

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