Provider Demographics
NPI:1821682030
Name:ROESEL, COURTNEY
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:
Last Name:ROESEL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1110 FLANDERS RD
Mailing Address - Street 2:
Mailing Address - City:FLANDERS
Mailing Address - State:NY
Mailing Address - Zip Code:11901-3868
Mailing Address - Country:US
Mailing Address - Phone:631-704-8015
Mailing Address - Fax:
Practice Address - Street 1:5225 RTE 347 STE 44
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON STATION
Practice Address - State:NY
Practice Address - Zip Code:11776-2060
Practice Address - Country:US
Practice Address - Phone:631-403-3318
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-28
Last Update Date:2021-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist