Provider Demographics
NPI:1861986143
Name:ROE, TIMOTHY JAY
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:JAY
Last Name:ROE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7982 DAWN DR
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48875-1956
Mailing Address - Country:US
Mailing Address - Phone:517-449-0192
Mailing Address - Fax:
Practice Address - Street 1:2909 E GRAND RIVER AVE
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48912-4300
Practice Address - Country:US
Practice Address - Phone:517-364-8695
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-19
Last Update Date:2018-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI26010001842255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Single Specialty