Provider Demographics
NPI:1063751790
Name:DELOOF-PRIMMER, ROSETTA MARIA (LCSW)
Entity type:Individual
Prefix:
First Name:ROSETTA
Middle Name:MARIA
Last Name:DELOOF-PRIMMER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8239 E WALNUT RDG
Mailing Address - Street 2:
Mailing Address - City:NEW CARLISLE
Mailing Address - State:IN
Mailing Address - Zip Code:46552-9075
Mailing Address - Country:US
Mailing Address - Phone:574-276-9571
Mailing Address - Fax:
Practice Address - Street 1:450 SAINT JOHN RD
Practice Address - Street 2:
Practice Address - City:MICHIGAN CITY
Practice Address - State:IN
Practice Address - Zip Code:46360-7354
Practice Address - Country:US
Practice Address - Phone:219-879-0676
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-31
Last Update Date:2014-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN33006230A104100000X
IN34006887A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100163580AMedicaid
IN485380Medicare PIN