MEDICARE: MISS BRITTANY MARIE ROZEBOOM

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	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1720543747
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS BRITTANY MARIE ROZEBOOM

Provider Business Mailing Address
First Line	:	PO BOX 3
Second Line	:
City	:	RANDOM LAKE
State	:	WI
Zip	:	53075-0003
Country	:	US
Telephone Number	:	912-547-1979
Fax Number	:

Provider Business Practice Location Address
First Line	:	6140 W EXECUTIVE DR STE B
Second Line	:
City	:	MEQUON
State	:	WI
Zip	:	53092-4499
Country	:	US
Telephone Number	:	888-754-0398
Fax Number	:

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

Provider Enumeration Date	:	02/04/2019
Last Update Date	:	01/27/2026

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