MEDICARE: TRAICE MARIE ROKITA

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	7101006298	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	7101006298	OTHER	MI	MICHIGAN STATE LICENSE

General Provider Information

NPI Number	:	1790346955
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TRAICE MARIE ROKITA

Provider Business Mailing Address
First Line	:	400 ANN ST NW
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49504-2052
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	400 ANN ST NW
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49504-2052
Country	:	US
Telephone Number	:	616-591-2905
Fax Number	:

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

Provider Enumeration Date	:	06/27/2019
Last Update Date	:	06/27/2019

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Directions to “ TRAICE MARIE ROKITA ” Practice Location

Language	Start Address	Practice Location

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