Provider Demographics
NPI:1326055914
Name:ROLSTEN, MARK (PSYD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:
Last Name:ROLSTEN
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:559 VINCENT ST
Mailing Address - Street 2:ATTN: 21 MDOS/SGOH-MENTAL HEALTH
Mailing Address - City:PETERSON AFB
Mailing Address - State:CO
Mailing Address - Zip Code:80914-1541
Mailing Address - Country:US
Mailing Address - Phone:719-556-7804
Mailing Address - Fax:866-867-7926
Practice Address - Street 1:559 VINCENT ST
Practice Address - Street 2:ATTN: 21 MDOS/SGOH-MENTAL HEALTH
Practice Address - City:PETERSON AFB
Practice Address - State:CO
Practice Address - Zip Code:80914-1541
Practice Address - Country:US
Practice Address - Phone:719-556-7804
Practice Address - Fax:866-867-7926
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2009-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO3184103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical