Provider Demographics
NPI:1093402141
Name:ROLLER, ELAINE ROSEMARY (BA)
Entity Type:Individual
Prefix:
First Name:ELAINE
Middle Name:ROSEMARY
Last Name:ROLLER
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2916
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92393-2916
Mailing Address - Country:US
Mailing Address - Phone:442-353-9887
Mailing Address - Fax:
Practice Address - Street 1:27252 JACKSON RD
Practice Address - Street 2:
Practice Address - City:APPLE VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92307-6632
Practice Address - Country:US
Practice Address - Phone:442-353-9887
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-19
Last Update Date:2023-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst