Provider Demographics
NPI:1730687518
Name:ROSE, WANMDIWI JESSI (PHD)
Entity type:Individual
Prefix:DR
First Name:WANMDIWI
Middle Name:JESSI
Last Name:ROSE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:WANMDIWI
Other - Middle Name:JESSI
Other - Last Name:FULGHAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:300 POPLAR LN
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:MT
Mailing Address - Zip Code:59833-6834
Mailing Address - Country:US
Mailing Address - Phone:713-494-3341
Mailing Address - Fax:
Practice Address - Street 1:600 CENTRAL AVE STE 311
Practice Address - Street 2:
Practice Address - City:GREAT FALLS
Practice Address - State:MT
Practice Address - Zip Code:59401-3157
Practice Address - Country:US
Practice Address - Phone:406-866-0013
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-26
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPY60720535103T00000X
MTPSY-PSY-LIC-2506103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist