Provider Demographics
NPI:1861875817
Name:MUDRY, ROXANN (LMSW)
Entity type:Individual
Prefix:
First Name:ROXANN
Middle Name:
Last Name:MUDRY
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2163 MARTIN ST
Mailing Address - Street 2:
Mailing Address - City:WESTLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48186-9393
Mailing Address - Country:US
Mailing Address - Phone:734-657-8041
Mailing Address - Fax:
Practice Address - Street 1:120 E LIBERTY ST STE 210
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48104-2156
Practice Address - Country:US
Practice Address - Phone:734-335-4747
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-08
Last Update Date:2019-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010999711041C0700X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical