Provider Demographics
NPI:1174718415
Name:UNDERWOOD, ROSETTA (MA, EDS)
Entity type:Individual
Prefix:MRS
First Name:ROSETTA
Middle Name:
Last Name:UNDERWOOD
Suffix:
Gender:F
Credentials:MA, EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:495 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBOURNE
Mailing Address - State:WV
Mailing Address - Zip Code:26149-9621
Mailing Address - Country:US
Mailing Address - Phone:304-758-2973
Mailing Address - Fax:
Practice Address - Street 1:495 PARK AVE
Practice Address - Street 2:
Practice Address - City:MIDDLEBOURNE
Practice Address - State:WV
Practice Address - Zip Code:26149-9621
Practice Address - Country:US
Practice Address - Phone:304-758-2973
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-10
Last Update Date:2007-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV610103T00000X, 103TB0200X
WV21004103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool