Basic Information
| Provider Information | |||||||||
| NPI: | 1144691064 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WHITLEY | ||||||||
| FirstName: | ROSELYN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MA, PLPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11814 MARKET PLACE AVE STE B | ||||||||
| Address2: | |||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 708166084 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2252236153 | ||||||||
| FaxNumber: | 2252462420 | ||||||||
| Practice Location | |||||||||
| Address1: | 223 FERNWOOD DR | ||||||||
| Address2: | SUITE A | ||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 708063130 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2259233733 | ||||||||
| FaxNumber: | 2259233735 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/19/2015 | ||||||||
| LastUpdateDate: | 06/18/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
ID Information
| ID | Type | State | Issuer | Description | 600720433 | 05 | LA | MEDICAID | 600964601 | 05 | LA | MEDICAID | 600751961 | 05 | LA | MEDICAID |