Provider Demographics
NPI:1639318421
Name:HERICKS, ROXANNE M
Entity Type:Individual
Prefix:
First Name:ROXANNE
Middle Name:M
Last Name:HERICKS
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 1:320 W CAMERON ST
Mailing Address - Street 2:
Mailing Address - City:TOMAH
Mailing Address - State:WI
Mailing Address - Zip Code:54660-2566
Mailing Address - Country:US
Mailing Address - Phone:608-372-4168
Mailing Address - Fax:
Practice Address - Street 1:1407 SAINT ANDREW ST STE 100
Practice Address - Street 2:
Practice Address - City:LA CROSSE
Practice Address - State:WI
Practice Address - Zip Code:54603-2378
Practice Address - Country:US
Practice Address - Phone:608-372-3290
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-02-18
Last Update Date:2009-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1836-120171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator