Basic Information
Provider Information
NPI: 1003004623
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: ROLLER
FirstName: HAROLD
MiddleName: DWAYNE
NamePrefix: MR.
NameSuffix:  
Credential: LCMFT
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 21350 W 153RD ST
Address2:  
City: OLATHE
State: KS
PostalCode: 660615413
CountryCode: US
TelephoneNumber: 9133222400
FaxNumber: 9136215730
Practice Location
Address1: 21350 W 153RD ST
Address2:  
City: OLATHE
State: KS
PostalCode: 660615413
CountryCode: US
TelephoneNumber: 9133222400
FaxNumber: 9136215730
Other Information
ProviderEnumerationDate: 10/09/2007
LastUpdateDate: 10/09/2007
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
106H00000X259KSY Behavioral Health & Social Service ProvidersMarriage & Family Therapist 

No ID Information.


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