Provider Demographics
NPI:1447903760
Name:ROLLER, DOUGLAS RAY (CDCA)
Entity type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:RAY
Last Name:ROLLER
Suffix:
Gender:
Credentials:CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2216 MCCLEARY JACOBY RD
Mailing Address - Street 2:
Mailing Address - City:CORTLAND
Mailing Address - State:OH
Mailing Address - Zip Code:44410-9426
Mailing Address - Country:US
Mailing Address - Phone:330-984-7475
Mailing Address - Fax:
Practice Address - Street 1:1628 SPRINGFIELD ST
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45403-1430
Practice Address - Country:US
Practice Address - Phone:937-603-5295
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-27
Last Update Date:2025-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA.190856101YA0400X
OH175T00000X, 171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC236Medicaid
OH5874OtherHEALTH PARTNERS
OH96BMedicaid
OH2910854Medicaid
OH568946544OtherBCBS