Provider Demographics
NPI:1922287994
Name:VAN ETTEN, ROSANNE RAE (MA)
Entity Type:Individual
Prefix:MRS
First Name:ROSANNE
Middle Name:RAE
Last Name:VAN ETTEN
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 36
Mailing Address - Street 2:
Mailing Address - City:SMITHLAND
Mailing Address - State:IA
Mailing Address - Zip Code:51056
Mailing Address - Country:US
Mailing Address - Phone:712-889-2140
Mailing Address - Fax:712-889-2140
Practice Address - Street 1:3223 HWY 141
Practice Address - Street 2:
Practice Address - City:SMITHLAND
Practice Address - State:IA
Practice Address - Zip Code:51056
Practice Address - Country:US
Practice Address - Phone:712-889-2140
Practice Address - Fax:712-889-2140
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-26
Last Update Date:2007-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0733410Medicaid