Healthcare Provider Details

I. General information

NPI: 1124084942
Provider Name (Legal Business Name): ROXANNE MAE ROSE PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/21/2006
Last Update Date: 02/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

217 GRANDVIEW AVE
DEVILS LAKE ND
58301-4123
US

IV. Provider business mailing address

217 GRANDVIEW AVE
DEVILS LAKE ND
58301-4123
US

V. Phone/Fax

Practice location:
  • Phone: 701-662-5590
  • Fax: 701-665-3252
Mailing address:
  • Phone: 701-662-5590
  • Fax: 701-665-3252

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number2096
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: