Provider Demographics
NPI:1033675616
Name:ROOSEN, DIANNE
Entity Type:Individual
Prefix:
First Name:DIANNE
Middle Name:
Last Name:ROOSEN
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 1:2 COLEMAN DR
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32084-2873
Mailing Address - Country:US
Mailing Address - Phone:727-967-1036
Mailing Address - Fax:
Practice Address - Street 1:2 COLEMAN DR
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32084-2873
Practice Address - Country:US
Practice Address - Phone:727-967-1036
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-19
Last Update Date:2019-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA16247235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist