Provider Demographics
NPI:1760205504
Name:PULLIAM, ROSHANDA EVETTE (SAC-IT)
Entity type:Individual
Prefix:MRS
First Name:ROSHANDA
Middle Name:EVETTE
Last Name:PULLIAM
Suffix:
Gender:F
Credentials:SAC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1537 S 5TH ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53204-2844
Mailing Address - Country:US
Mailing Address - Phone:414-299-9018
Mailing Address - Fax:
Practice Address - Street 1:2801 INTERNATIONAL LN STE 205
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53704-3152
Practice Address - Country:US
Practice Address - Phone:608-241-4285
Practice Address - Fax:608-241-4286
Is Sole Proprietor?:No
Enumeration Date:2024-10-31
Last Update Date:2024-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI20298-130101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor