Healthcare Provider Details

I. General information

NPI: 1760522049
Provider Name (Legal Business Name): ROSEANN M WOODKA PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/07/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

926 E JACKSON BLVD
ELKHART IN
46516-4351
US

IV. Provider business mailing address

926 E JACKSON BLVD
ELKHART IN
46516-4351
US

V. Phone/Fax

Practice location:
  • Phone: 574-522-6292
  • Fax: 574-522-0481
Mailing address:
  • Phone: 574-522-6292
  • Fax: 574-522-0481

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number20041649
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: