Provider Demographics
NPI:1124084942
Name:ROSE, ROXANNE MAE (PHD)
Entity type:Individual
Prefix:MS
First Name:ROXANNE
Middle Name:MAE
Last Name:ROSE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:217 GRANDVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:DEVILS LAKE
Mailing Address - State:ND
Mailing Address - Zip Code:58301-4123
Mailing Address - Country:US
Mailing Address - Phone:701-662-5590
Mailing Address - Fax:701-665-3252
Practice Address - Street 1:217 GRANDVIEW AVE
Practice Address - Street 2:
Practice Address - City:DEVILS LAKE
Practice Address - State:ND
Practice Address - Zip Code:58301-4123
Practice Address - Country:US
Practice Address - Phone:701-662-5590
Practice Address - Fax:701-665-3252
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-21
Last Update Date:2012-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND2096103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND19124Medicaid
ND23117OtherBC/BC
ND24043OtherND BC/BS
MN181620900Medicaid
MN284K8DAOtherMN BC/BS
NDN715569OtherMEDICARE PTAN