Basic Information
| Provider Information | |||||||||
| NPI: | 1750041596 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROAT | ||||||||
| FirstName: | TRACEY | ||||||||
| MiddleName: | LYNNE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | RSST | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WESTENDORF | ||||||||
| OtherFirstName: | TRACEY | ||||||||
| OtherMiddleName: | LYNNE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1515 ALLENDALE DR | ||||||||
| Address2: | |||||||||
| City: | SAGINAW | ||||||||
| State: | MI | ||||||||
| PostalCode: | 486384403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9898602781 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2700 W GENESEE AVE | ||||||||
| Address2: | |||||||||
| City: | SAGINAW | ||||||||
| State: | MI | ||||||||
| PostalCode: | 486023723 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9897991266 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/21/2021 | ||||||||
| LastUpdateDate: | 12/21/2021 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 12/21/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 6803086673 | MI | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.