Provider Demographics
NPI:1588779722
Name:ROESEL, ROSALYN (RN, MSN, PHD)
Entity type:Individual
Prefix:DR
First Name:ROSALYN
Middle Name:
Last Name:ROESEL
Suffix:
Gender:F
Credentials:RN, MSN, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1983 DELEGAL DR NE
Mailing Address - Street 2:
Mailing Address - City:TOWNSEND
Mailing Address - State:GA
Mailing Address - Zip Code:31331-7425
Mailing Address - Country:US
Mailing Address - Phone:912-667-5079
Mailing Address - Fax:912-832-4693
Practice Address - Street 1:1983 DELEGAL DR NE
Practice Address - Street 2:
Practice Address - City:TOWNSEND
Practice Address - State:GA
Practice Address - Zip Code:31331-7425
Practice Address - Country:US
Practice Address - Phone:912-667-5079
Practice Address - Fax:912-832-4693
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-20
Last Update Date:2009-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY001032103T00000X, 103G00000X, 103TC0700X, 103TF0000X, 103TF0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000366627AMedicaid
GA000366627AMedicaid