Provider Demographics
NPI:1316075104
Name:ROSCH, PAMELA RUTH (MA)
Entity type:Individual
Prefix:MRS
First Name:PAMELA
Middle Name:RUTH
Last Name:ROSCH
Suffix:
Gender:F
Credentials:MA
Other - Prefix:MRS
Other - First Name:PAMELA
Other - Middle Name:RUTH
Other - Last Name:BURRIDGE ROSCH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MA
Mailing Address - Street 1:5016 EDGEWATER DR
Mailing Address - Street 2:
Mailing Address - City:SAVAGE
Mailing Address - State:MN
Mailing Address - Zip Code:55378-5614
Mailing Address - Country:US
Mailing Address - Phone:952-440-9130
Mailing Address - Fax:952-440-9130
Practice Address - Street 1:4005 W 65TH ST
Practice Address - Street 2:SUITE 214
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-1720
Practice Address - Country:US
Practice Address - Phone:612-251-7998
Practice Address - Fax:952-440-9130
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-01
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP0260103TC1900X
MN232106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN2H117BUOtherBLUE CROSS
MN1795503-00Medicare UPIN