Provider Demographics
NPI:1851741292
Name:ROSERIE, MADELENE (RMHCI)
Entity Type:Individual
Prefix:
First Name:MADELENE
Middle Name:
Last Name:ROSERIE
Suffix:
Gender:F
Credentials:RMHCI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1919 W 10TH ST APT 28
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33805-3388
Mailing Address - Country:US
Mailing Address - Phone:863-899-4536
Mailing Address - Fax:
Practice Address - Street 1:4422 E COLUMBUS DR
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33605-3233
Practice Address - Country:US
Practice Address - Phone:813-384-4203
Practice Address - Fax:813-984-6729
Is Sole Proprietor?:No
Enumeration Date:2016-06-16
Last Update Date:2016-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL13928101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL060650200Medicaid