Provider Demographics
NPI:1639398779
Name:ROOSA, NANCY E (PSYD)
Entity Type:Individual
Prefix:DR
First Name:NANCY
Middle Name:E
Last Name:ROOSA
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 SAGAMORE AVE
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02155-2145
Mailing Address - Country:US
Mailing Address - Phone:781-710-1881
Mailing Address - Fax:
Practice Address - Street 1:124 SAGAMORE AVE
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02155-2145
Practice Address - Country:US
Practice Address - Phone:781-710-1881
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA8421103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist