MEDICARE: TERRENCE ALLEN ROGALLA MSSW, LCSW, CEAP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	6802-123	WI

General Provider Information

NPI Number	:	1659403947
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TERRENCE ALLEN ROGALLA MSSW, LCSW, CEAP

Provider Business Mailing Address
First Line	:	738 ARROWHEAD BLVD
Second Line	:
City	:	WILTON
State	:	WI
Zip	:	54670-6006
Country	:	US
Telephone Number	:	608-343-8681
Fax Number	:

Provider Business Practice Location Address
First Line	:	738 ARROWHEAD BLVD
Second Line	:
City	:	WILTON
State	:	WI
Zip	:	54670-6006
Country	:	US
Telephone Number	:	608-343-8681
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/12/2007
Last Update Date	:	03/29/2012

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