Provider Demographics
NPI:1083868970
Name:ROLACK, CHARLESETTA (LICSW)
Entity Type:Individual
Prefix:MS
First Name:CHARLESETTA
Middle Name:
Last Name:ROLACK
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2100 WILSON AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55119-4034
Mailing Address - Country:US
Mailing Address - Phone:651-771-1301
Mailing Address - Fax:651-771-2542
Practice Address - Street 1:2100 WILSON AVE
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55119-4034
Practice Address - Country:US
Practice Address - Phone:651-771-1301
Practice Address - Fax:651-771-2542
Is Sole Proprietor?:No
Enumeration Date:2008-11-05
Last Update Date:2008-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN18701101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health