Provider Demographics
NPI:1770629164
Name:ETHERINGTON, ROSALIE (PHD)
Entity Type:Individual
Prefix:DR
First Name:ROSALIE
Middle Name:
Last Name:ETHERINGTON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:ROSALIE
Other - Middle Name:
Other - Last Name:ETHERINGTON-DODSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD
Mailing Address - Street 1:1712 ELMWOOD PL
Mailing Address - Street 2:
Mailing Address - City:JAMESTOWN
Mailing Address - State:ND
Mailing Address - Zip Code:58401-5748
Mailing Address - Country:US
Mailing Address - Phone:701-269-2979
Mailing Address - Fax:
Practice Address - Street 1:1712 ELMWOOD PL
Practice Address - Street 2:
Practice Address - City:JAMESTOWN
Practice Address - State:ND
Practice Address - Zip Code:58401-5748
Practice Address - Country:US
Practice Address - Phone:701-269-2979
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2023-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDND 268103T00000X
ND268103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1460283Medicaid