Provider Demographics
NPI:1821312430
Name:ROSKOS, PHILIP T (PHD)
Entity Type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:T
Last Name:ROSKOS
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 1:26901 BEAUMONT BLVD STE 3D
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48033-3849
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:18181 OAKWOOD BLVD STE 411
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-4082
Practice Address - Country:US
Practice Address - Phone:313-982-5150
Practice Address - Fax:313-982-5157
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-25
Last Update Date:2022-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2008035687103G00000X, 103T00000X, 103TR0400X
MI6301015810103TC0700X, 103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitation