Provider Demographics
NPI:1619023512
Name:ROSVOLD, VIRGINIA RAE (MSW)
Entity Type:Individual
Prefix:MS
First Name:VIRGINIA
Middle Name:RAE
Last Name:ROSVOLD
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3448 NW 123RD PL
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97229-3799
Mailing Address - Country:US
Mailing Address - Phone:503-617-4569
Mailing Address - Fax:503-617-9489
Practice Address - Street 1:16110 SW REGATTA LN
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97006-8942
Practice Address - Country:US
Practice Address - Phone:503-617-4569
Practice Address - Fax:503-617-9489
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR21011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORP39193Medicare UPIN