Provider Demographics
NPI:1760504252
Name:ROETHE, JUDITH ANN (MS CAPSW)
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:ANN
Last Name:ROETHE
Suffix:
Gender:F
Credentials:MS CAPSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 N MIDVALE BLVD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53705-3265
Mailing Address - Country:US
Mailing Address - Phone:608-280-3959
Mailing Address - Fax:608-238-1929
Practice Address - Street 1:310 N MIDVALE BLVD
Practice Address - Street 2:SUITE 202
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53705-3265
Practice Address - Country:US
Practice Address - Phone:608-280-3959
Practice Address - Fax:608-238-1929
Is Sole Proprietor?:No
Enumeration Date:2007-04-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1107-121101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39717100Medicaid