Basic Information
| Provider Information | |||||||||
| NPI: | 1962593996 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PHOENIX | ||||||||
| FirstName: | ROSEY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MSW-ACSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PETITT | ||||||||
| OtherFirstName: | ROSEANN | ||||||||
| OtherMiddleName: | M | ||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MSW-ACSW | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 199 HOME RD | ||||||||
| Address2: | |||||||||
| City: | JUNEAU | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530391401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9203863500 | ||||||||
| FaxNumber: | 9203863812 | ||||||||
| Practice Location | |||||||||
| Address1: | 199 HOME RD | ||||||||
| Address2: | |||||||||
| City: | JUNEAU | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530391401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9203863500 | ||||||||
| FaxNumber: | 9203863812 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/27/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 697-123 | WI | Y | Behavioral Health & Social Service Providers | Psychologist |
No ID Information.