Provider Demographics
NPI:1023216769
Name:DEPAUL, ROXANNE (PHD)
Entity Type:Individual
Prefix:
First Name:ROXANNE
Middle Name:
Last Name:DEPAUL
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:126 NAUTILUS DR
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53705-4330
Mailing Address - Country:US
Mailing Address - Phone:608-513-9398
Mailing Address - Fax:
Practice Address - Street 1:1504 MADISON AVE
Practice Address - Street 2:
Practice Address - City:FORT ATKINSON
Practice Address - State:WI
Practice Address - Zip Code:53538
Practice Address - Country:US
Practice Address - Phone:920-563-9357
Practice Address - Fax:920-568-6545
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-03
Last Update Date:2010-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI43-154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42720900Medicaid
WI43-154OtherSTATE LIC SPEECH-LANG
00266999OtherASHA NUMBER