Provider Demographics
NPI:1235575887
Name:WIERZBA, ROSE
Entity Type:Individual
Prefix:
First Name:ROSE
Middle Name:
Last Name:WIERZBA
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 1:2004 VALPARAISO ST
Mailing Address - Street 2:
Mailing Address - City:VALPARAISO
Mailing Address - State:IN
Mailing Address - Zip Code:46383-3138
Mailing Address - Country:US
Mailing Address - Phone:219-477-5646
Mailing Address - Fax:
Practice Address - Street 1:1424 8TH ST SE
Practice Address - Street 2:
Practice Address - City:DEMOTTE
Practice Address - State:IN
Practice Address - Zip Code:46310-9058
Practice Address - Country:US
Practice Address - Phone:219-964-3773
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-21
Last Update Date:2013-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN39002472A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health