Provider Demographics
NPI:1740413632
Name:ROSCOE, JULIA VANDER WENDE (MED, MA, BCBA)
Entity Type:Individual
Prefix:
First Name:JULIA
Middle Name:VANDER WENDE
Last Name:ROSCOE
Suffix:
Gender:F
Credentials:MED, MA, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3730 S LINDBERGH BLVD # 246
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63127-1376
Mailing Address - Country:US
Mailing Address - Phone:314-246-0587
Mailing Address - Fax:
Practice Address - Street 1:3730 S LINDBERGH BLVD # 246
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63127-1376
Practice Address - Country:US
Practice Address - Phone:314-246-0587
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-26
Last Update Date:2013-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
1-05-2421OtherBCBA CERTIFICATION NUMBERR