Provider Demographics
NPI:1790912616
Name:ROZELLE, GEORGE R (PHD)
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:R
Last Name:ROZELLE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2800 BAHIA VISTA ST
Mailing Address - Street 2:SUITE 400
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34239-2742
Mailing Address - Country:US
Mailing Address - Phone:941-954-9959
Mailing Address - Fax:941-954-9960
Practice Address - Street 1:2800 BAHIA VISTA ST
Practice Address - Street 2:SUITE 400
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34239-2742
Practice Address - Country:US
Practice Address - Phone:941-954-9959
Practice Address - Fax:941-954-9960
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-18
Last Update Date:2009-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH2078101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLZ4762OtherBLUE CROSS BLUE SHIELD OF FLORIDA