Provider Demographics
NPI:1639145790
Name:CLARK, ROSEANNE (PHD)
Entity Type:Individual
Prefix:
First Name:ROSEANNE
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7974 UW HEALTH CT
Mailing Address - Street 2:
Mailing Address - City:MIDDLETON
Mailing Address - State:WI
Mailing Address - Zip Code:53562-5531
Mailing Address - Country:US
Mailing Address - Phone:608-829-5485
Mailing Address - Fax:
Practice Address - Street 1:6001 RESEARCH PARK BLVD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53719
Practice Address - Country:US
Practice Address - Phone:608-263-6100
Practice Address - Fax:608-262-9246
Is Sole Proprietor?:No
Enumeration Date:2006-02-27
Last Update Date:2009-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1147103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist