Provider Demographics
NPI:1215266309
Name:ROOS, MICHAEL DWAYNE (MA, LMFT)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:DWAYNE
Last Name:ROOS
Suffix:
Gender:M
Credentials:MA, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:719 SLEATER KINNEY RD SE STE 212
Mailing Address - Street 2:
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98503-1138
Mailing Address - Country:US
Mailing Address - Phone:360-519-4256
Mailing Address - Fax:
Practice Address - Street 1:719 SLEATER KINNEY RD SE STE 212
Practice Address - Street 2:
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98503-1138
Practice Address - Country:US
Practice Address - Phone:360-519-4256
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-18
Last Update Date:2017-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALF 60497884106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2069009Medicaid