Provider Demographics
NPI:1710613450
Name:SAILSBURY, ROMAN ERIC
Entity Type:Individual
Prefix:
First Name:ROMAN
Middle Name:ERIC
Last Name:SAILSBURY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:133 PARKWOOD DR
Mailing Address - Street 2:
Mailing Address - City:WRENSHALL
Mailing Address - State:MN
Mailing Address - Zip Code:55797-9068
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4140 RICHARD AVE STE 200-300
Practice Address - Street 2:
Practice Address - City:HERMANTOWN
Practice Address - State:MN
Practice Address - Zip Code:55811-2869
Practice Address - Country:US
Practice Address - Phone:218-514-5230
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-26
Last Update Date:2022-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician