Healthcare Provider Details

I. General information

NPI: 1174718415
Provider Name (Legal Business Name): ROSETTA UNDERWOOD M.A., ED.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/10/2007
Last Update Date: 09/10/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

495 PARK AVE
MIDDLEBOURNE WV
26149-9621
US

IV. Provider business mailing address

495 PARK AVE
MIDDLEBOURNE WV
26149-9621
US

V. Phone/Fax

Practice location:
  • Phone: 304-758-2973
  • Fax:
Mailing address:
  • Phone: 304-758-2973
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number610
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number610
License Number StateWV
# 3
Primary TaxonomyN
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number21004
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: