Provider Demographics
NPI:1922618701
Name:ROSTAS, JODIE RENEE (MA)
Entity Type:Individual
Prefix:MS
First Name:JODIE
Middle Name:RENEE
Last Name:ROSTAS
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 1:960 FULTON LN NE
Mailing Address - Street 2:
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32905-5517
Mailing Address - Country:US
Mailing Address - Phone:321-506-1875
Mailing Address - Fax:
Practice Address - Street 1:960 FULTON LN NE
Practice Address - Street 2:
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32905-5517
Practice Address - Country:US
Practice Address - Phone:321-506-1875
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-05
Last Update Date:2020-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty