Provider Demographics
NPI:1366719445
Name:ROMAN, WILLIE III
Entity type:Individual
Prefix:MR
First Name:WILLIE
Middle Name:
Last Name:ROMAN
Suffix:III
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:WILLIE
Other - Middle Name:J
Other - Last Name:ROMAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:26184 WEST OUTER DRIVE
Mailing Address - Street 2:
Mailing Address - City:LINCOLN PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48146
Mailing Address - Country:US
Mailing Address - Phone:313-389-7594
Mailing Address - Fax:
Practice Address - Street 1:26184 OUTER DR
Practice Address - Street 2:
Practice Address - City:LINCOLN PARK
Practice Address - State:MI
Practice Address - Zip Code:48146-2084
Practice Address - Country:US
Practice Address - Phone:313-389-7594
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-17
Last Update Date:2011-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker