Provider Demographics
NPI:1174304679
Name:ROSKOM, EMILY
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:
Last Name:ROSKOM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1286 CROWN CT APT 6
Mailing Address - Street 2:
Mailing Address - City:DE PERE
Mailing Address - State:WI
Mailing Address - Zip Code:54115-3875
Mailing Address - Country:US
Mailing Address - Phone:920-450-5934
Mailing Address - Fax:
Practice Address - Street 1:1511 W MAIN AVE STE 200
Practice Address - Street 2:
Practice Address - City:DE PERE
Practice Address - State:WI
Practice Address - Zip Code:54115-9556
Practice Address - Country:US
Practice Address - Phone:920-450-5934
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-10
Last Update Date:2023-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst