Healthcare Provider Details

I. General information

NPI: 1174304679
Provider Name (Legal Business Name): EMILY ROSKOM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2023
Last Update Date: 05/22/2026
Certification Date: 05/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1575 ALLOUEZ AVE
GREEN BAY WI
54311-5625
US

IV. Provider business mailing address

3245 RIVERSIDE DR APT 4
GREEN BAY WI
54301-1656
US

V. Phone/Fax

Practice location:
  • Phone: 192-036-7891
  • Fax:
Mailing address:
  • Phone: 920-450-5934
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: